Office or scheme: [Ministry / Department / State office and the scheme or service]
Application or reference number: [number, if any]
Date applied or last contact: [DD-MM-YYYY]

What happened:
[2 to 5 short lines, in date order]

What I have already done:
On [date] I [applied / wrote / visited] to [office], reference no. [____]. [Reply received on [date] saying ____. / No reply.]

What I am asking for:
[issue the certificate / release the payment of Rs. ____ / correct the record / give a written reason]

Documents attached:
1. [Application or receipt]
2. [Earlier letters and replies]
3. [ID or other proof, if needed]

Name: [your name]
Mobile: [registered mobile number]
District and state: [district], [state]