At [state place] the [state date], in presence of [name notary public] notary public, and of the witnesses subscribing, I [name and designation of heir in possession], heir of entail in possession of the lands and others after mentioned, viz. [take in full description from titles], which lands and others are held by me under a deed of entail dated [state date of entail], and recorded [state particulars of registration], take instruments in the hands of the said notary public subscribing that the said lands and others are now held by me free from the conditions, provisions, and clauses prohibitory, irritant, and resolutive of the entail, by virtue of the Act [specify this Act]; and I consent to the registration hereof in the register of tailzies, and also in the books of council and session and others competent, therein to remain for preservation, and thereto constitute my procurators, &c.
In witness whereof I and the said notary public have subscribed this instrument of disentail [complete the testing clause in ordinary form].
[Signature of heir of entail in possession.] [Signature of notary public.] N.P.A.B., Witness.C.D., Witness.