New South Wales Consolidated Acts

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INEBRIATES ACT 1912 - SCHEDULE 5

SCHEDULE 5

(Section 17)

New South Wales,
to wit.

Be it remembered that on theday of19,of(andof) personally came before me, one of His Majesty’s justices of the peace, and acknowledged themselves (or himself) to owe to our Sovereign Lord the King the sum ofto be made and levied of their several (or his) goods and chattels, lands, and tenements respectively to the use of our said Lord the King, His Heirs, and Successors if the saidshall, during a period ofmonths from the date of the presents, fail to [here set out conditions of recognizance].

Taken and acknowledged the day and year first abovementioned atin the said State, before me-



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