Plaintiff shows to the court as follows:

1. On _______,19__, Plaintiff served on Defendant a request for admission of the following facts:

(a) _________________________________________________________

____________________________________________________________

(b) _________________________________________________________

____________________________________________________________

[A copy of the request is attached hereto as Exhibit A.]

2. On ____, 19__, Defendant served on Plaintiff his statement in reply, [and a copy of said statement is attached as Exhibit B]; said statement contains no specific denial of the matters of which an admission was requested of the Defendant nor does it fully admit or deny those matters.

Wherefore, Plaintiff moves the court that the facts set forth in paragraph 1 be taken as established, or in the alternative, that an amended answer be served.

____________________________,

Attorney for Plaintiff

[Address of Attorney for Plaintiff]