罪犯______，男（女），______年______月______日生，______族，原户籍所在地______，因____________罪经____________人民法院于______年___________月______日以（）____字第______号刑事判决书判处________________，附加__________________，刑期自____________年______月______日至______年______月______日止，于______年_____月______日送我狱服刑改造。服刑期间执行刑期变动情况：_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_________。

该犯在近期确有_______________表现，具体事实如下：________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________......

此致

XX人民法院