Plaintiff A.B. requests defendant C.D. within _____ days after service of this request to make the following admissions for the purpose of this action only and subject to all pertinent objections to admissibility which may be interposed at the trial:
(Here list the documents and describe each document.)
(Here list the statements.)
Signed: _______________________________________________________________
Attorney for Plaintiff
Address: ______________________________________________________________
SDCL tit. 15, ch. 6, app C to SDCL 15-6, form 22