FORM 42 (Section 827)
Certificate of Non-payment of Costs of Appeal
In the Court of
(Style of Cause)
I hereby certify that A.B. (the appellant or respondent, as the case may be) in this appeal, having been ordered to pay costs in the sum of dollars, has failed to pay the said costs within the time limited for the payment thereof.
Dated this day of A.D. , at .
Clerk of the Court of
(Seal)