Form No. 215a.
5,000-23-12-07.
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| | DECLARATION OF ABANDONMENT |
| | In the Matter of the ________________________ of section ____________
Township ____________ Range ____________ of the ____________ Meridian
Homestead ____________________________Pre-emption_____________________________
I._________________________________ of
_________________________________ on the ____________day
of _________________________________ 19_ _, and I now ask to have said entry cancelled,
and be permitted to take up another homestead for the following reasons, namely: |
| (Here state reasons) | (1) __________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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| (Here state nature and extent of residence, and if, not on homestead where performed) | (2) __________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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| (Here describe the improvements and state value thereof) | (3) __________________________________________________________________
______________________________________________________________________
______________________________________________________________________
|
| (Give area of breaking and cultivation each year.) | ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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| That I have not received directly or indirectly, nor have I been promised, nor do I expect
to receive any consideration of any kind for allowing said entry to be cancelled
And I make this solemn declaration conscientiously believing it to be true, and knowing
that it is of the same force and effect as if made under oath and by virtue of the Canada Evidence
Act, 1893.
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DECLARED before me __________________________
__________________________at _________________ Signature __________________________
______________________________________________
this _________________day of _________________ Address ___________________________
A.D. 190_
*______________________________________________________________
*J.P., Com'r in B.R., &c to sign at star.
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