(A)   Owner's certificate.
   Each final 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, which was conveyed to us by deed as recorded in Dearborn County Deed Record Number         Page Number         , do hereby certify that we have laid off, platted and subdivided, and hereby lay off, plat and subdivide, said real estate in accordance with the within plat.
This subdivisions shall be known and designated as,                                                     , an addition to                                                           . All streets and alleys shown and not heretofore dedicated, are hereby dedicated to the public.
Front 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.
There are strips of ground           feet in width as shown on this plat and marked "Easement," and are hereby dedicated to the public for the use of public utilities for the installation of water, gas and sewer mains, poles, ducts, lines and wires, subject at all times to the proper authorities and to the easement herein reserved. No buildings or other structures are to be erected or maintained upon said strips of land, but owners of lots in this subdivision shall take their titles subject to the rights of the public utilities.
(Additional dedications and protective covenants, or private restrictions, would be inserted here upon the subdivider's initiative or the recommendation of the commission; important provisions are those specifying the use to be made of the property and, in the case of residential use, the minimum habitable floor area.)
The foregoing covenants, (or restrictions), are to run with the land and shall be binding on all parties and all persons claiming under them until January 1, 20  , (a 25 year period is suggested), at which time said covenants, (or restrictions), shall be automatically extended for successive periods of ten years, unless changed by vote of a majority of then owners of the building sites covered by these covenants, ore restrictions, which shall remain in full force and effect.
The right to enforce these provisions by injunction, together with the right to cause the removal, by due process of law, of any structure or part thereof erected or maintained in violation hereof, is hereby dedicated to the public, and reserved to the several owners of the several lots in this subdivision and to their heirs and assigns.
      WITNESS our Hands and Seals this day of                                   , 20   
            :   SS:
Before me the undersigned, a Notary Public, in and for said County and State, personally appeared                                                             ,                                                 ,                                                        , and each separately and severally acknowledged the execution of the foregoing instrument as his or her voluntary act and deed for the purpose therein expressed.
      Witness my hand and Notarial Seal this day of                 , 20    .
      My Commission expires:                                 NOTARY PUBLIC resides in                                           Dearborn County, Indiana.
   (B)   City Engineer certificate.
            :   SS:
I do hereby certify to the Plan Commission that the streets and storm sewers have been installed in accordance with the approved Improvement Plans and that the facilities have been inspected, tested and approved.
               City Engineer
               City of Lawrenceburg, Indiana
   (C)   Utility Director certificate.
            :   SS:
I do hereby certify to the Plan Commission that the water mains, sanitary sewers and electrical distribution systems have been installed in accordance with the approved Improvement Plans and that the facilities have been inspected, tested and approved.
                  Utility Director
                  City of Lawrenceburg, Indiana
   (D)   Plan Commission certificate.
            :   SS:
      Approved and accepted this day of                                   , 20    .
               City of Lawrenceburg Plan Commission
   (E)   Common Council certificate.
      Approved and accepted this day of                                 , 20    .
      Common Council of                                    
      By                                                   ,
                                                                                          , Clerk-Treasurer
   (F)   Declaration of survey and Surveyor's report; Surveyor's certificate.
      TO: [ Owner's(s') Name(s)] and the City of Lawrenceburg Plan Commission
The attached plat and description (File No.                         ) were prepared               (date)                from a field survey conducted under my direct supervision by employees of (name of survey company). All monuments were set in this survey unless otherwise indicated on the accompanying plat and the field notes for this survey are filed in the office of (name of survey company). Bearings are (assumed/ from a 3.765 acre survey/ etc.) and measurements are shown    in feet and decimals thereof. The subdivision shown hereon is intended to conform to zoning regulations of the City of Lawrenceburg Ordinance                   and the variances stated hereon, if any.
In accordance with the Indiana Survey Standards as defined in Indiana Administrative Code 865 I.A.C. 1-12 ("Rule 12"), the following observations and opinions are submitted regarding the various uncertainties in the locations of the lines and corners established on this survey as a result of uncertainties in the reference monuments, record documents, lines of occupation, and the random errors in measurement (Theoretical Uncertainty).
   (Specific explanation of how the boundary of this tract was located, etc.)
The Theoretical Uncertainty (due to random errors in measurement) of the corners of the subject tract established this survey is within the specifications of a Class                           Survey (+/- 0. feet) as defined in I.A.C. 865.
   I hereby certify that I am a Land Surveyor holding Indiana Registration S-                              this                 date of               20      .
(Name of Survey Company)
(Telephone No.)
(Ord, - -, passed - -)