I, the undersigned authority,
certify that all taxes and assessments due or exigible against that certain
tract of land designated as ___________________________, Tract No._______
(name of vendor)
__________________County, State of _______________________containing __________
hectares (acres), more or less, and more particularly described as follows:
HAVE BEEN FULLY PAID AND SATISFIED TO DATE EXCEPT:
Dated this _________day of _________________, 19 ___, at _______________.