By a certain contract in writing made on _________[date] between _________ of _________ in the County of _________ and State of _________, seller, and _________ of _________, in the County of _________ and State of _________, purchaser, which contract was duly recorded in the _________ office of _________ County, on _________[date], in book _________, on page _________, purchaser, in consideration that seller conveyed to _________ the following described land, situated in the County of _________, State of _________: _________, covenanted and agreed to pay to seller $_____, as follows: _________, and further covenanted to pay all taxes, assessments or impositions that should be legally levied upon the land subsequent to the year _________.

Purchaser further covenanted in the contract, that in case of a failure on h— part to make any of the payments, or any part of them, or to perform any of the covenants agreed by h— in it to be made or performed, then in such case the contract should, at the option of seller, be forfeited and determined, and all payments made on it should be forfeited to seller, and the seller should have the right to reenter and take possession of the land; and it was also mutually agreed between the parties to the contract, that the time of payment should be an essential part of the contract.

Purchaser, has made default in the payment of _________.

Therefore, I, _________, seller, by virtue of the power mentioned in the contract, and by reason of the failure of purchaser to perform as above stated, have elected to declare the contract, and all payments made on it, forfeited and determined, and by these presents do declare my election to consider the contract forfeited and determined; and I declare my right to retain all payments made on the contract, and my right of reentry upon and possession of the land.