This document provides a draft form for submitting AI reference document change requests. Each request requires a separate submission. The form collects information including the date, agenda item, submitter affiliation, a title of twenty-five words or less, the location of the impacted section or paragraph number, original text, revised text, rationale, and discussion notes. The form includes fields for secretariat use to record whether requests are accepted, accepted as amended, deferred for further discussion, not accepted, or withdrawn.