[Proposition of Debtor.]

In the District Court of the United States,

____the debtor____above named, being unable to pay____debts in full, do hereby, pursuant to the provisions of the acts of Congress relating to bankruptcy, and subject to the priorities therein declared, propose a composition to____creditors of____cents on the dollar of the debts due from____to them respectively, to be paid in money at the times hereinafter stated, and to be evidenced and secured in manner following, that is to say: [here set forth the terms of the proposed composition.]