On the __________ day of the week, the __________ day of the month of __________ in the year __________ after creation of the world, according to the calendaric calculations that we count here, in the city __________, which is situated on the__________ river, and situated near springs of water, I, __________ the son of __________, who today am present in the city __________, which is situated on the__________ river, and situated near springs of water, willingly consent, being under no duress, to release, discharge, and divorce you [to be] on your own, you, my wife __________, daughter of __________, who are today in the city of __________, which is situated on the__________ river, and situated near springs of water, who has hitherto been my wife. And now I do release, discharge, and divorce you [to be] on your own, so that you are permitted and have authority over yourself to go and marry any man you desire. No person may object against you from this day onward, and you are permitted to every man. This shall be for you from me a bill of dismissal, a letter of release, and a document of absolution, in accordance with the law of Moses and Israel.
_________ the son of _________ — witness�_________ the son of _________ — witness.