In the Magistrate's Court for the District/Region of .....................................................................................

held at .....................................................................................................................

I, ..................................................., of .........................................., hereby apply to inspect the record of Case No. ............................. of 20..........

(If number of record is not known, then as follows:)

I, ..................................................., of ........................................, hereby apply to inspect the record of the case between .............................................. (plaintiff) and ...................................... (defendant).

Search to begin with the month of .............................................. 20.........

.......................................................

Signature

(If the applicant is a party to the case or the attorney of such party, his or her capacity should be stated after his or her signature.)