If a subdivision is located outside the city limits, but within one mile of the city limits and provides for the dedication of area for streets or other public use, the plat shall provide a form in blank to record the acceptance of the plat by the County Commissioner's Court as follows:
"STATE OF TEXAS COUNTY OF (GREGG OR RUSK as applicable)
I, _____, Clerk of the commissioner's Court of (Gregg or Rusk) County, Texas, do hereby certify that the foregoing map was approved and accepted by the commissioner's Court on the _____ day of _____, 20 _____, as shown by order or record in minutes of the Court in Vol. _____ on page _____.
Witness my hand and the seal of the Court as office in Beeville, Texas, this the _____ day of _____, 20 _____."