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(miejscowość i data)

Znak sprawy
RSOW

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

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

Załączając akta sprawy nr RSOW..................................... w sprawie ..................................................................

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wnoszę o zatwierdzenie*:

1) przeszukania dokonanego na podstawie art. 44 § 1, 2, 4, 5 kpw*,

2) zatrzymania przedmiotów dokonanego na podstawie art. 217 § 1 i 3 kpk, art. 44 § 4, 5 kpw,

w dniu ................................................................................................................................... o godz. ............................

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

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Druk opracowano w WDŚ KWP w Gdańsku

UZASADNIENIE

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(podpis kierownika jednostki)

*) niepotrzebne skreślić