State of South Carolina,

County of __________

This is to certify that by virtue and authority of the provisions of Chapter 19 of Title 49 of the Code of South Carolina the board of supervisors of __________ Drainage District of South Carolina have, and do hereby, levy the sum of $___ as the annual installment of tax for the year 19___ of the total tax levied under the provisions of § 49-19-1610 of said chapter which total tax has heretofore been certified to the clerk of the court of common pleas of your county. And said board of supervisors of said drainage district, by and with the authority of § 49-19-2310 of said chapter has levied also the sum of $___ as a maintenance tax for said year. Said annual installment of tax and maintenance tax on the real estate and other property situate in your county are set out in the following table in which are: first, the names of the owners of such lands as they appeared in the decree of the court organizing said district; second, a brief description of such lands and other property opposite the names of such owners; third, the amount of said installment of tax levied on each tract of land and other property; and fourth, the amount of maintenance tax levied against the same. Said taxes shall be collectible and payable the present year at the same time that State and county taxes are due and collected and you are directed and ordered to demand and collect said taxes at the same time you demand and collect the State and county taxes due on the same lands and other property; and this "Drainage Tax Book" shall be your warrant and authority for making such demand and collection.

Witness the signature of the president of the board of supervisors, attested by the seal of said district, and the signature of the secretary of said board this ___ day of __________, A. D. 19_.

President of District.[Seal.] Secretary of District.

Then shall follow a table or schedule showing in properly ruled columns: first, the names of the owners of the lands as they appeared in the decree of the court organizing the district; second, a brief description of the lands and other property opposite the names of the owners; third, the amount of the annual installment tax levied on each tract of land and other property; fourth, the amount of the maintenance tax; fifth, a blank column in which the collector shall record the several amounts as collected by him; sixth, a blank column in which the collector shall record the date of payment of the different sums; seventh, a blank column in which the collector shall record the names of the persons paying the several amounts. The columns in which the annual installment tax and the maintenance tax, if any, appear shall be correctly totaled and the total amount shall correspond to the amount set out in the above-mentioned certificate. The certificate and table shall be prepared in the form of a well-bound book which shall be endorsed and named "Drainage Tax Book __________ Drainage District, __________ County, South Carolina, for the year 19___."

Such endorsement shall also be printed at the top of each page in such book.