UNTO THE RIGHT HONOURABLE THE LORD JUSTICE GENERAL, LORD JUSTICE-CLERK AND LORDS COMMISSIONERS OF JUSTICIARY
[or Unto The Honourable The Sheriff of (name of sheriffdom)
At (place)]
[or Unto The Justices In The District Court Of (name of district) At (place)]
Application
by
(name of offender) (address) [or Prisoner
in the Prison of (place)]
[or name and address of applicant with responsibility for monitoring offender’s compliance with restriction of liberty order]
APPLICANT
HUMBLY SHEWETH
1. That a restriction of liberty order, a copy of which is annexed to this application, was made in respect of (name of offender) on (date) in the High Court of Justiciary sitting [ or in the sheriff court or in the district court] at (place).
2. That the applicant applies to the court in terms of subsection (1) of section 245E of the Criminal Procedure (Scotland) Act 1995 to revoke [or vary] the order for the following reason–
(statement of reason)
MAY IT THEREFORE PLEASE YOUR LORDSHIP[S] [OR THE COURT]:
to [revoke the restriction of liberty order] [vary the restriction of liberty order by (statement of variation sought in terms of subsection (2) (a) of the said section 245E)],
or
to do otherwise as to your Lordship[s] [or to the court] shall seem proper.
IN RESPECT WHEREOF
(Signed)
Offender
[or Solicitor for offender]
[or applicant with responsibility for monitoring compliance]
(Where a solicitor signs, the address and telephone number of the solicitor).