Certification by territorial authority or regional council

I certify that the boundaries shown on the plan numbered

are the same as the boundaries determined by a resolution of the

(name of territorial authority or regional council)

on

and

replaces

does not replace any existing plan/s.

replaces the following existing plan/s:

plan/s

Please list plan numbers in a comma separated list.

Name

Position title

Chief Executive or other appropriate officer

Your email address

The email address to which a copy of this form will be sent for signing.