Form prescribed

1  The attached form is prescribed for the purposes of section 103 of the Social Service Tax Act.

IN THE MATTER OF THE SOCIAL SERVICE TAX ACT, R.S.B.C. 1996, CHAPTER 431, SECTION 103 AND IN THE MATTER OF THE INTEREST OF ..................................................................... [Name]

IN .................................................................................................................................................................

........................................................[P.I.D. Number and Full Legal Description of Land]

CERTIFICATE OF INDEBTEDNESS

I certify that:

1 .................................................................................................................................. [Debtor Name]

............................................................................................................................... [Debtor Address]

has either

(a) not collected or not remitted tax, or both, or

(b) not paid tax

under the Social Service Tax Act.

2 The amount of taxes remaining uncollected, unremitted, or unpaid, that were required to be collected, were collected but not remitted, or were not paid, and any related interest and penalty on those taxes at the date of this Certificate is $.................... .

AND TAKE NOTICE that on registration of this Certificate in the Land Title Office, the amount of the indebtedness to Her Majesty the Queen in right of the Province of British Columbia is a lien against the land described above.

Dated at........................................, British Columbia on ..................................[Date]

......................................................................
Commissioner
Social Service Tax Act

[am. B.C. Reg. 4/2010, s. 3.]