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：________________________________________
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　　该犯在近期确有_______________表现，具体事实如下：
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　　为此，根据《中华人民共和国监狱法》第______条、《中华人民共和国刑法》第_____条____款、《中华人民共和国刑事诉讼法》第_______条_____款的规定，建议对罪犯_______予以假释。特提请裁定。
　　　　　　此致
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