市   区人民法院：

        你院受理的（    ）  法民  初/重字第     号案件，即我与               （被申请人名称/案由）                                纠纷一案，因                                                                   （理由）                                                ，需要对（XXX持有人持有的XXXX证据）：                                          

                                                                    

                                                                      

                                                                       

                                                                      

进行保全。        

上述证据可以证明的案件事实为                                     

                                                                     

                                                                       

                                                                      

                                                                      

                                                                       

                                                                      

                                                                      

 

现申请你院采取对上述证据的查封、扣押等保全措施。

如因我方申请错误给被申请人造成不应有的损失的，由我方负责赔偿。

特此申请

 

申请人              

  年    月    日