| Heading and notes: | No form number. Two lines of vertical text at the left. | 
| Message area: | Blank (5A & 5B) or faint ruled. | 
| Reverse side: | Blank. | 
| Colours (text & form): | Black on deep pink. | 
| Size of form overall: | 169 × 213 mm. | 
| Size of datestamp box: | 37 × 37 mm. | 
Details of use and rarity.
| Form sub-number | Schedule number | Earliest recorded date | Rarity rating | 
| DU-5A | RRR | ||
| DU-5B | RRR | ||
| DU-5C | St. 3481 | 21 July 1914 at Adelong, NSW. | RRR | 
| DU-5D | RRR |