SURVEYOR'S REPORT.

To the supervisors of the town of __________, county of __________, and state of __________:

The undersigned having been employed by you to make a survey of a road in said town would report that the following is a correct survey thereof, as made by me under your directions, to-wit: (Give an accurate description of the road by course and distance) and that below is a correct plot of said road according to said survey. (Dated and signed.)