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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. | Average Amount of Notes in Circulation during the Four Weeks ending the Day of | Average total Amount of Coin held during Four Weeks ending | |||
| £5 and upwards. | Under £5. | Total. | Gold. | Silver. | ||||
I hereby certify, That each of the Bankers named in the above Return who have issued an Amount of Notes beyond that authorized in their Certificate] with the Exception of A.B. or CD., as the Case may be,] have held an Amount of Gold and Silver Coin not less than that which they are required to hold during the Period to which this Return refers. Dated ____ Officer of the Stamps.
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