FORM 58C

CERTIFICATE OF ASSESSMENT OF COSTS

(General Heading — Form 4A or 4B)

CERTIFICATE OF ASSESSMENT OF COSTS

I CERTIFY that I have assessed the costs of (identify party) in this proceeding (or as may be) under the authority of (give particulars of order or specify rule or statutory provision), and I ALLOW THE SUM OF $ .

(Date)

signature of assessment officer