I hereby certify that the foregoing Statement is correct, and that the Treasurer's authority for making the above payments was signed by the following:

Chairman.
Members present
at the Meeting.

Dated this

day of

19-

Clerk of the Asylum.

CERTIFICATE OF CONFIRMATION BY COMMITTEE.

(To be signed at the Meeting held next after the Finance Meeting at which the above payments were

ordered to be made.)

I hereby certify that the foregoing was this day submitted to, examined, and confirmed by the Committee.

Dated this-

- day of

19

Chairman of the Meeting.

Lunatic Asylum.

The Particulars and Price of the Goods or Work are to be inserted, and the Invoice or Account

returned when the Order is executed.

This No. shall be consecutive for the half-year, and shall be in print.

Insert in these spaces the name of the Tradesman, the goods to be supplied, and the place at which they are to be delivered, or the work is to be done, as the case may be.

This No. must be entered by the Storekeeper according to the order of the receipt, and be consecutive for the half-year.

NOTE.--This Order, with the invoice or account in blank, is to be detached from the block thereof, and sent to the Tradesman; the Order is to be kept by the Tradesman, and the Invoice or Account returned when the Order is completely executed, a ticket being sent containing the like entries with every delivery, when there is more than one.

Payment will be made on presentation of this notification with the form of receipt hereunder duly signed by you

This document must be presented through a Bank.