Whereas, by His Majesty's Commission under the Great Seal of Great Britain bearing Date the 13th Day of October in the year of Our Lord 1812, and in the 52d Year of His Majesty's Reign, the Lords Commissioners for executing the Office of Lord High Admiral are required and authorized to issue forth and grant Letters of Marque and Reprisal to any of His Majesty's Subjects or others, whom we shall deem fitly qualified in that Behalf for apprehending, seizing, and taking the Ships, Vessels and Goods belonging to the United States of America, or to any Persons being Subjects of the United States of America (save and except for any Ships to which license has been granted) and to bring the same to Judgement in any of His Majesty's Courts of Admiralty with his Dominions, for Proceedings and Adjudication and Condemnation to be thereupon had, according to the Court of Admiralty, and the Laws of Nations; These are, therefore, to will and require you to cause a Letter of Marque and Reprisals to be issued out of the High Court of Admiralty unto _____________________ Commander of the ________________ Burthern of about ____ Tons, mounted with ___ Carriage Guns carrying Shot of ___ Pounds Weight and navigated with _______ men, whereas the said _______________________ is commander, to apprehend, seize, and take the Ships, Vessels and Goods Belonging to the United States of America, or to any persons being Subjects of France, according to His Majesty's Commission and Instruction aforesaid. And you are to keep an exact Journal of Proceedings, and therein particularly to take notice of all Prizes taken, the nature of such Prizes, the Time and Place of their being taken, the value of them as near as you can judge, as also the Situation, Motion and Strength of the Americans, as well as you can discover by the best Intelligence you can get; of which you shall from Time to Time as you shall have Opportunity, to transmit an Account to our Secretary. Provide always that security be given according to His Majesty's Instructions before mentioned; the Said Letters of Marque and Reprisal to continue in force until further orders, for which this shall be your Warrant.

Given under my Hand, and the Great Seal of the Province this ____ day of _____________ 18 __ in the _______ year of His Majesty's Reign.
By His Excellency's Command.