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ศาล
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ระหว่ จำเลย
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าง
ข้อหาหรือฐานความ
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จำนวนทุน
ทรัพย์................................................................................................บาท......
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ขอยื่นฎีกาคัดค้าน.................................ศาลอุทธรณ์ลงวัน
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ที่ได้อ่าน....................................................เมื่อวัน
ที่..............เดือน.............................................พ.ศ. ๒๕................
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