| (Section 4(4)) |
| CERTIFICATE OF SAMPLE OF SEIZED SUBSTANCE (SIGNATURE NOT PROVIDED) |
| I HEREBY CERTIFY that on the day of |
| 20 , I took a sample of: |
| (description of substance) |
| |
| |
| |
| from the bulk and that the bulk was weighed or otherwise measured and the sample was taken and weighed or otherwise measured in the presence of |
| of |
| (Name) | (Address) |
| *Accused/*Attorney-at-law/*Agent |
| Measurement of bulk g./kg/ml/l. |
| Measurement of sample g./kg/ml/l. |
| I FURTHER CERTIFY that the *Accused/*Attorney-at-law/*Agent refused to sign or initial the container containing the sample. |
| Signature and Rank |
| Police Officer |
| * (delete if inapplicable) |