APPENDIX A: CERTIFICATION FORMS
DEED OF DEDICATION
   (A)   Each secondary plat submitted to the Commission for approval shall carry a deed of dedication in substantially the following form:
We, the undersigned, ________________________________owners of the real estate shown and described herein, do hereby certify that we have laid off, platted and subdivided, and do hereby lay off, plat and subdivide, said real estate in accordance with the within plat.
This subdivision shall be known and designated as ________________________, an addition to _________________________. All streets, alleys, parks, and other public lands shown and now heretofore dedicated, are hereby dedicated, to the public.
Front and side yard building setback lines are hereby established as shown on this plat, between which lines and the property lines of the street, there shall be erected or maintained no building or structure. Witness our hands and seals this_____________________day of_________________, 20___.
                     ___________________________________
                     ___________________________________
                     ___________________________________
STATE OF INDIANA )
         ) SS
COUNTY OF ADAMS)
Before me, the undersigned Notary Public, in and for the said City and State, personally appeared ______________________ and _________________________,and each separately and severally acknowledged the execution of the foregoing instrument as his or her voluntary act and deed; for the purposes therein expressed. Witness my hand and Notarial Seal this_______day of_______,20__.
   (B)   Each secondary plat submitted to the Commission for approval shall carry a certificate signed by a Registered Land Surveyor in substantially the following form.
I,___________________ hereby certify that I am a Registered Land Surveyor, licensed in compliance with the laws of the State of Indiana; that this plat correctly represents a survey completed by me on______________,that all the monuments and material are accurately shown.
   (SEAL)       _____________________________________________
   (C)   Certificate of Secondary Plat Approval.
I hereby certify that under I.C. 36-7-19 et seq. and after proper publication of Public Notice and Hearing this plat was given secondary approval on________________, 20___.
Designated Official_______________________________________
                     Plan Commission
   (D)                     APPROVED
   Common Council of the City of Berne, Indiana
   ___________________________________________
   ___________________________________________
   ____________________________________________
   ____________________________________________
   ____________________________________________
   This_________________ day of_______, 20___.
   (E)                        APPROVED
COUNTY SURVEYOR OF
ADAMS COUNTY, INDIANA
   __________________________________________
   This_________day of __________________, 20___.
   (F)                        APPROVED
   ADAMS COUNTY BOARD OF HEALTH
   ADAMS COUNTY, INDIANA
   _____________________________________
   _____________________________________   
   _____________________________________
   This____________________day of_______, 20___.
(Ord. 466, § 4-10-1, passed 5-11-98)