Certificate under special Oath
Province of Québec,
Municipality of ..............
I, the undersigned, P. T., (style) residing in (residence) being duly sworn, do depose and say: that I served the within special notice in writing (or the special notice in writing hereunto annexed) upon (as set forth in Form 4.)
In testimony whereof, I give this certificate, this .............. day of the month of .............. nineteen hundred ..............
P. T., or
(style,)
his
P. X T.
mark, affixed in
presence of N. O.,
Witness.
Sworn this .............. day of .............. 19.............., at (place) before me, the undersigned .............. Justice of the Peace (or Warden, etc.)
H. P.,
(Style)