I Further Certify That the labor expended and improvements made
upon and for the benefit of the
(lode or placer) location(s)
embraced in the said mining claim by claimant(s) or
grantors are fully stated in my report. The character, extent, location,
and itemized value are specified in full detail. No portion of, or interest
in, said labor and improvements so credited to this claim has been included
in the estimate of expenditures upon any other claim.
____________________________________ _____________________________________
(Location) (Signature of Mineral Surveyor)