四分律刪補隨機羯磨 2.198

2.198

「長老一心念！我比丘某甲，今受七日法出界外，為某事故，還來此中安居。白長老知。」（三說。）

"Āyuṣmat, give me your single-minded attention! I, the bhikṣu N.N., now undertake the procedure for seven days to depart beyond the boundary, and for the sake of such-and-such an affair, will return here to dwell for the retreat. I declare this to inform the elder." (To be spoken three times.)