Fill and Sign the Dedication Property Form

BOOK PAGE INDEX: , COUNTY, MISSISSIPPI STATE OF MISSISSIPPI COUNTY OF DEDICATION OF AND FOR PUBLIC STREETS, AND UTILITY EASEMENTS AND OTHER IMPROVEMENTS FOR AND IN CONSIDERATION of the sum of one dollar ($1.00), cash in hand paid and other good and valuable consideration, the sufficiency and receipt of all of which is hereby acknowledged, , a Mississippi banking corporation, a/k/a , Grantor, does hereby transfer, assign, dedicate, warrant and convey to the City of , Mississippi, a municipal corporation, Grantee, the following described land for use as public streets, lying and being situate in the City of , County, Mississippi, to - wit: SEE EXHIBIT " " ATTACHED HERETO AND INCORPORATED HEREIN BY REFERENCE. A PLAT OF THE PARCEL DESCRIBED IN EXHIBIT " " IS ATTACHED HERETO AS EXHIBIT " " AND INCORPORATED HEREIN BY REFERENCE. Also conveyed by Grantor to Grantee are the utility easements described in Exhibit “ ” and depicted in Exhibit " ," for public drainage and public utilities, and all water lines, sewer lines, storm drains, valves, manholes and all streets, together with all other improvements situated thereon and all appurtenances thereunto belonging, now lying in and above the land above described. It is agreed and understood that the public streets situated within the above described parcel of land shall be and are hereby designated as and , as designated on the plat attached hereto as Exhibit " ." WITNESS my signature this the day of , 20 . , a Mississippi banking corporation, a/k/a Grantor BY:       , CHIEF FINANCIAL OFFICER 1 STATE OF MISSISSIPPI COUNTY OF PERSONALLY appeared before me, the undersigned authority in and for said County and State, within my jurisdiction, the within named , duly identified before me, who acknowledged that he/she is the Chief Financial Officer of , a Mississippi banking corporation, a/k/a and that for and on behalf of , a Mississippi banking corporation, a/k/a , and as its act and deed, he/she signed and delivered the above and foregoing instrument for the purposes mentioned on the day and in the year therein mentioned, after first having been duly authorized by , a Mississippi banking corporation, a/k/a , so to do. GIVEN UNDER MY HAND AND OFFICIAL SEAL OF OFFICE, this the day of , 20 .       NOTARY PUBLIC MY COMMISSION EXPIRES:       Grantor's address and telephone number: Telephone: 2 RECORD OF ACCEPTANCE BY THE CITY OF The Mayor and Board of Aldermen of the City of , Mississippi, accepted the parcel of land and the improvements thereon, herein dedicated for public streets, drainage and utility purposes, during its regular meeting on the day of , 20 , said action appearing in the official minutes of the City of , Mississippi, recorded in Minute Book at Page . CITY OF , MISSISSIPPI BY:       MAYOR ATTEST:       , CITY CLERK PREPARED BY: Telephone Number Facsimile Number 3