Example 2
 

This letter constitutes my/our official request to have my/our name(s) removed from the records of the Church of Jesus Christ of Latter-day Saints, as specified in the General Handbook of Instructions, 1989 Edition, chapter eight, page four. 

These instructions to you state that you, as the bishop, are to be certain that I understand the following:

that withdrawing a name cancels the effects of baptism; 
withdraws the priesthood from a male member; 
and suspends temple sealings and blessings. 
I do understand these things, and make this formal, written request that my name be removed from the records of the church.

Therefore, I ask you to promptly complete the form "Request for Administrative Action," and forward it to the Stake President. You will need to send me a letter, telling me that you have done so, and that the Stake President will hold the form for 30 days. With no further action from me, at the end of those 30 days, the Stake President will forward this letter and the form to the Office of the First Presidency.

Sincerely,

____________ 

CC - Stake President