Paragraph F1

“ Notice prospectively converting real burden into health care burden

Superior:

(see note for completion 1)

Description of land which is to be servient tenement:

(see note for completion 2)

Terms of real burden:

(see note for completion 3)

Statement that purpose was to promote the provision of facilities for health care:

(with supporting evidence: see note for completion 3)

Any counter obligation:

(see note for completion 3)

Title to the superiority:

(see note for completion 4)

Service:

(see note for completion 5)

Signature on behalf of superior:

Date: .”