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|Name and Title, as set forth in Licence.||Name of the Firm.||Head Office, or principal Place of Issue.||Amount of Circulation authorized by Certificate.||Notes in Circulation during the Week ending Day of|
(1)Average of Four Weeks of all Notes.
|Account of Coin held by the 'Banker at the head Office or principal Place of Issue, on the Day of||Average total Amount of Coin held by the Bank during Four Weeks ending|
|£5 and upwards.||Under £5.||£5 and upwards.||Under £5.||Gold.||Silver.||Gold.||Silver.|
|Held on each Day of the Week preceding that Day.|
I ______________________________________ being [the Banker, Chief Cashier, Managing Director, or Partner of the Bank, or other Officer duly authorized by the Director, as the Case may be,] do hereby certify, That the above is a true Account of the Notes in Circulation and Coin held by the said Bank during the Week above written. Dated the Day of 18__. (Signed)
To be inserted at the End of each Period of Four Weeks.
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