Certification by Local Government Commission

I certify that the boundaries shown on the plan numbered

are the same as the boundaries determined by the Local Government Commission on

pursuant to

replaces

does not replace any existing plan/s.

replaces the following existing plan/s:

plan/s

Please list plan numbers in a comma separated list.

Name

Position title

Chief Executive or other appropriate officer

Your email address

The email address to which a copy of this form will be sent for signing.