Form 21

To the session of the Reformed Presbyterian congregation of _________________. Your informant respectfully states that _______________, a member of your congregation, is believed guilty of a serious sin, contrary to the Word of God and to the profession of the Reformed Presbyterian Church, in that _____________ on or about _________________, did ______________, and that ______ ought to be proceeded against by your court to determine whether or not the charge is true.

Date ____________________________________________________________

Name ___________________________________________________________

List of witnesses:

List of material offered in evidence: