Section 28(1).

I, A. B. of, do solemnly and sincerely declare (a) that I am entitled to hold the pawn-ticket in respect of the article (or articles) described below, (b) that the said pawn-ticket has been* and (c) that the said pawn-ticket has not been sold or transferred by me to any person.

*State whether lost, mislaid, destroyed, stolen or taken by fraud.

The article (or articles) above referred to is (or are) the following: -

AND I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938.

(Signed) A. B.

Declared before me by A. B.

who is personally known to me (or who

is identified to me by C. D.

who is personally known to me) at

__________________________________________

this______________day of______________

__________________________________________

__________________________________________

TAKE NOTICE if this Statutory Declaration is, to the knowledge of the person making it, false or misleading in any material respect he shall be guilty of an offence and shall be liable on summary conviction thereof to a fine not exceeding £1,500 or, at the discretion of the court, to imprisonment for a term not exceeding 3 months or to both such fine and such imprisonment.

Unless this printed form is taken before a notary public, a commissioner for oaths or a peace commissioner and declared to and signed and delivered back to the pawnbroker not later than the day of day of, 19, the article (or articles) mentioned in it will be delivered to any person producing the pawn-ticket.