[SCHEDULE 5C Form of 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:          .”

This notice is sent by your feudal superior; that is to say by [the Scottish Ministers] or [specify National Health Service trust].

By this notice the feudal