I,____________________ , a _______________________ of the Department of ____________ hereby certify that on the ______ day of ___________19__, I made a personal examination and inspection of that certain tract or parcel of land situated in the County of ______________, State of ____________, designated as Tract No. _______and containing _________ hectares (acres), (proposed to be) acquired by the United States of America in connection with the _____________________________________project, from ________________________________________________________________________.
1. That I am fully informed as to the boundaries, lines and corners of said tract; that I found no evidence of any work or labor having been performed or any materials having been furnished in connection with the making of any repairs or improvements on said land; and that I made careful inquiry of the above-named vendor (and of the occupants of said land) and ascertained that nothing had been done on or about said premises within the past months that would entitle any person to a lien upon said premises for work or labor performed or materials furnished;
2. That I also made inquiry of the above-named vendor (and of all occupants of said land) as to his (their) rights of possession and the rights of possession of any person or persons known to him (them) and neither found any evidence nor obtained any information showing or tending to show that any person had any rights of possession or other interest in said premises adverse to the rights of the above-named vendor or the United States of America;
3. That I was informed by the above-named vendor (and by all other occupants) that to the best of his (their) knowledge and belief there is no outstanding unrecorded deed, mortgage, lease, contract or other instrument adversely affecting the title to said premises;
4. That to the best of my knowledge and belief after actual and diligent inquiry and physical inspection of said premises there is no evidence whatever of any vested or accrued water rights for mining, agricultural, manufacturing or other purposes; nor any ditches or canals constructed by or being used thereon under authority of the United States, nor any exploration or operations whatever for the development of coal, oil, gas, or other minerals on said lands; and that there are no possessory rights now in existence owned or being actively exercised by any third party under any reservation contained in any patent or patents heretofore issued by the United States for said land;
5. That to the best of my knowledge and belief based upon actual and diligent inquiry made there is no outstanding right whatsoever in any person to the possession of said premises nor any outstanding right, title, interest, lien or estate, existing or being asserted in or to said premises except such as are disclosed and evidenced by the public records; and
6. That said premises are now wholly unoccupied and vacant except for the occupancy of ___________________ as tenant(s) at will, from who disclaimer(s) of all right, title, and interest in and to said premises, executed on the ________ day of ______________19___, has (have) been obtained.
Dated this _______ day of _________________, 19__.