.........................................…………… (nazwa i numer rejestru albo znak sprawy) ………………………………………. ^(nazwa jednostki Policji prowadzącej postępowanie)

Prokurator .............................................................

w ..............................................................................

d d m m r r r r

Załączając akta postępowania przygotowawczego w sprawie .....................................................

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wnoszę o zatwierdzenie przeszukania / zatrzymania rzeczy * dokonanego

g g m m d d m m r r r r

u / w * ...........................................................................................................................................

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Uzasadnienie

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(podpis kierownika jednostki)

*) niepotrzebne skreślić

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