Part Form 20.12A-B Form of application under section 245E(1) of the Criminal Procedure (Scotland) Act 1995

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