_______公安局
                                         提请批准延长侦察羁押期限意见书
                                        （存 根）
                                        _________________________________________
                                         字[    ]     号
                                        案件名称：_______________________________
                                        案件编号：_______________________________
                                        犯罪嫌疑人：______ 性别：______年龄：____
                                        住    址：_______________________________
                                        单位及职业：_____________________________
                                        逮捕时间：_______________________________
                                        延长时间：_______________________________
                                        提请延长期限：___________________________
                                        送往单位：_______________________________
                                        批 准 人：_______________________________
                                        批准时间：_______________________________
                                        办 案 人：_______________________________
                                        办案单位：_______________________________
                                        填发时间：_______________________________
                                        填 发 人：_______________________________