THE complaint of R L, Receiver of Land Revenue for the Land District of , who comes before me, J S Esquire, a Justice of the Peace [or Community Magistrate] in and for New Zealand [or a Community Magistrate], this day of 19 , and complains that certain fees, amounting in the whole to the sum of $ , are now due and payable in respect of a certain Crown grant of [Describe land by numbers of sections or blocks, and name of land district, as in grant], and that A B, of , is [or are] the grantee [or grantees, or one of the grantees] named in the said grant [or, and that a legal estate of inheritance in the land comprised in the said grant is now vested in A B, of , and C D (or A B, of , and others)]. Taken before me, on the day and year first above written, at . J S, Justice of the Peace [or Community Magistrate].