Name, occupation, and address of person to whom land is granted:

Nature of estate or interest granted:

Area and description of land to be granted in exchange or (part exchange) for the land taken, purchased, or acquired or for the land injuriously affected or for the damage done:

Date from which entitled:

Encumbrances, liens, and interests to affect land to be granted:

Reservations and restrictions to affect land to be granted:

I hereby certify that the above particulars are correct and that the Minister of Lands, or Minister of Railways, or other notifying authority [describe] has approved the granting of such land.