請求准予易科罰金聲請狀 Application to Convert the Imprisonment Sentence to a Fine 案號: 年度 字第 號 股別： Case No.: year zhi No. Section:
聲請人姓名 Applicant Name	國民身分證統一編號/護照號碼/居留證號 National ID No./ Passport No./ Alien Resident Certificate No.	Tel.
The Request
一、聲請人因 案件經臺灣 法院 以 年度 字第 號判處 □有期徒刑 年 月□拘 役 日 確定，請依法准予易科罰金。 The Applicant has been sentenced to a □fixed-term imprisonment years and days □short-term imprisonment days under the case year zhi No. by the Taiwan Court. Under the final ruling, please grant the conversion of the imprisonment sentence to a fine according to the law. 二、聲請人因□身體□教育□家庭□職業關係，如送監執行，深恐執行將有困難， 爰依刑法第四十一條之規定，請求准予易科罰金。 2. Due to the□ physical condition□education□family□career of the Applicant,it would be difficult to execute the Petitioner’s sentence of imprisonment. Please grant the conversion of the imprisonment sentence to a fine pursuant to Article 41 of the Criminal Code of the Republic of China. 三、證明文件: 3. Supporting Documents:
此 致 福建連江地方檢察署 TO Fuchien Lienchiang District Prosecutors Office 聲請人 (簽名蓋章) (經聲請人閱覽無誤後簽名蓋章) Applicant (Signature/Stamp) (Reviewed and confirmed by the Petitioner) 中 華 民 國 年 月 日 Date: (mm)/ (dd), (yyyy)

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