STATE OF WISCONSIN
Town of ________
________ County
To the clerk of [name of municipality from which territory was transferred]:
The undersigned, clerk of the Town of ________, ________ County, Wisconsin, certifies that the following is the correct metes and bounds description of the land area transferred from [name of municipality] to the Town of ________, ________ County, Wisconsin, effective ________ ___, 20__: [metes and bounds description].
Dated this ______ day of ________, 20__.
[Signature of clerk of town to which territory was transferred]
Note: The same certification must be made to the clerk of the school district in which the transferred territory is located.
