To: _________[title insurance company]

This is to certify, that on _________[date], I made an accurate physical survey of the premises standing in the name of _________ situated at _________[city], _________[county], _________[state] known as street numbers _________ and shown on the accompanying survey entitled: _________.

I made a careful inspection of those premises and of the buildings located on those premises at the time of making such survey, and again on _________[date], and at the time of such latter inspection I found _________ to be in possession of those premises as _________(tenant or owner).

I further certify as to the existence or nonexistence of the following at the time of my last inspection:

Dated at _________ on _________.

_________, Civil Engineer

Instructions

For Survey and Surveyor's Certificate

A survey to be acceptable to _________ Title Insurance Company, must be prepared in U.S. standard of measurements and if within corporate limits of any town, village or city, must be a "transit" survey and not a "compass" survey. Preference will always be given to surveys showing bearings referred to true north but all surveys which show bearings must designate the meridian referred to whether true, magnetic or arbitrary and if true meridian is not used approximate deflection must be noted on the plat.

1. Boundaries. Every survey, whether of farm or city property, must indicate the physical character of the boundary lines, that is, whether fence, wall, watercourse, highway, etc., and if no physical evidence of boundaries exist, such fact must be noted. Any material variations from the record lines by fences, walls or structures, whether on the property surveyed or adjoining, must be shown, with the extent of such variations. If any of the boundaries or lines of record coincide with lot or property lines on any filed map, or are adopted from previous surveys, whether by the same surveyors or otherwise, such facts should be shown on the plat. The surveyor is required to check the description of adjoining owners, when furnished to surveyor and show the extent of any variations between the boundaries as stated in that description and those of the property surveyed.

2. Rights-of-Way, Cemeteries, etc. The surveyor must indicate any watercourses, drains, sewers, roads, paths or trails crossing the property, the closing of which might affect the rights of adjoining owners, whether legal or assumed. The surveyor must also show any existing cemetery or burying grounds on surveyed or adjacent property.

3. Streets and Alleys. Names of streets and alleys must be shown with the distance from the nearest corner to beginning point of property surveyed. Width of street and sidewalk in front or at side of premises should be shown with width of alley in rear or side of premises.

4. Party Walls. The nature, character, location and width of all walls on or near boundary lines should be shown. Show all projections beyond face of wall and indicate the portion of wall on the property and the portion on adjoining property, and whether subject to beam rights. The thickness of walls throughout entire length should be shown. If building on premises has no independent wall but uses any wall of adjoining premises, this condition should be shown and explained. The same requirements apply where conditions are reversed.

5. Adjoining Owners and Lot Numbers. Indicate on survey the names of adjoining owners on all sides of the premises. Lot numbers of the property in question and of adjoining lots must be shown.

6. Encroachments. Encroachments of building and of structural appurtenances, such as fire escapes, bay windows, etc., by or on adjoining property, or on abutting streets, must be indicated with the extent of such encroachments.

7. Building and Lot Lines. All buildings on property must be shown with dimensions and relation to lot and building lines. If conditions in chain of title or zoning ordinances require building to be set back specified distances from street or property line survey must show measured distance from the building to the line. In acreage surveys buildings may be plotted to scaled positions.

8. Area Contiguity. Show acreage of the property except in cases of small lots.

9. If survey comprises several parcels, show interior lines and facts sufficient to insure contiguity. We should be furnished with a consolidated description. Caution should be used to see that there are no strips or gores.

10. Courses and Distances. Courses and distances should be properly denoted, showing stakes or other monumentations appearing on the premises. Map should show arrow pointing north and give scale of distances.

11. Certificates of Survey. All maps must show city or town, county and state where premises are located with such other notations as will accurately identify property surveyed. The certificate on the survey must be dated as of date survey was made, signed by the surveyor, and be to the effect that the survey was actually made on the ground as per record description and is correct, and that there are no encroachments either way across the property lines except as shown on the survey.

12. The survey accompanying the "Surveyor's Report and Certification" should be a map or plat of the premises in question which should be prepared and certified by the surveyor in accordance with the requirements set forth above.