First Announcement
Beloved in the Lord, it is our painful duty as officebearers of this church to inform you that one of our fellow members, (name[optional] ), has committed the serious and offensive sin of (blank) and persists unrepentant to this day, despite our prayers and admonitions. Through his/her persistence, our brother/sister is breaking the covenant bond with the Lord and his people. Because sacraments are signs and seals of this relationship with our Savior and with one another, we have already been compelled to bar our brother/sister from participation in the sacraments.

As members of this church of Jesus Christ, we should be deeply concerned when one of our fellow members obstinately turns his/her back on the Christian way and refuses to repent. We are and remain responsible for one another (Gen. 4:9; Gal. 6:1-2; and 1 Cor. 12:12ff.). Therefore, let all of us pray that our brother/sister may respond positively to the admonitions of the church and return to the God and Father of our Lord Jesus Christ, who is seeking him/her in grace and faithfulness (Matt. 18:10-14; Luke 19:10).

Second Announcement
Beloved in the Lord, we informed you previously that as officebearers of this church we barred a fellow member, (name) , from the sacraments. We did so because he/she committed the serious and offensive sin of (blank) and failed to show true repentance despite our frequent admonitions.

With a heavy heart we must tell you that his/her suspension from the sacraments, and all admonitions since that time, have not produced in our brother/sister any evidence of a desire to be restored to the covenantal relationship with the Lord and his people.

We have discussed this matter with Classis (name), and were advised that if our brother/sister does not repent, we may proceed to the extreme remedy of his/her excommunication from the church of Jesus Christ.

Therefore, all of us are urged to continue to pray for our brother/sister and to plead with him/her that he/she may mend his/her ways and return to the Lord and his people in genuine repentance and faith. Our Lord does not wish that the sinner should perish but desires that he/she should return from his/her ways and live (Ezek. 18; Matt. 18).

Third Announcement
Beloved in the Lord, the officebearers of this church have twice informed you of the sin committed and the offense given by our fellow member, (name). We informed you that our brother/sister was barred from participation in the sacraments because he/she failed to show true repentance.

Our loving concern since that time, however, has not led him/her to demonstrate any sign of true repentance and faith. Because he/she persists in breaking the covenantal relationship with the Lord and his people, we are compelled to proceed with the final step of discipline, namely, the excommunication of our brother/sister from the church of the Lord. If our brother/sister does not show any evidence of genuine repentance, he/she, to our deep sorrow, will be excommunicated in this church on (date). If any member of the church knows of any valid reason why we should not proceed, we urge that person to inform the consistory.

Let all of us continue to pray for (name) and to plead with him/her so that he/she may not harden his/her heart completely, but return to the God and Father of our Lord Jesus Christ, with true confession of sin.

Excommunication
Beloved in the Lord, our fellow member, (name) , has brought discredit to the body of Christ by his/her sin, and in spite of the patient care of this church, remains unrepentant to this day. Accordingly, we as officebearers of this church are compelled with great sorrow to proceed with the final step of discipline, namely, his/her excommunication from the church of the Lord. We do this in obedience to the command of God in his Word (Matt. 18:15-18; 1 Cor. 5:1-5, 11-13; 1 Tim. 5:20).

This excommunication is necessary so that we may maintain the honor of God, remove offense from the church of Christ, and lead the erring one to repentance. We pray that this action may cause our brother/sister to seek forgiveness of sin, union with Christ, and restoration into the covenant family of God and his people.

Prayer
Holy Father, we are humbled before you at this time. What we are about to do grieves us deeply. We do it, Lord, with fear and trembling, conscious of our imperfection, yet also of the responsibility you have given your church in using the keys of the kingdom. Grant that our action may build up your church and cause none to stumble. This we ask in the name and for the sake of Jesus Christ, our Lord. Amen.

Declaration
In the name and the authority of our Lord Jesus Christ, we hereby excommunicate (name) from the church of our Lord. We believe that God himself excludes him/her from the fellowship of Christ, the holy sacraments, and all the blessings of faith as long as he/she persists in his/her impenitence.

Exhortation
Let all of us pray that the Holy Spirit grant (name) grace to recognize his/her sin, work in him/her genuine repentance, and restore him/her to fellowship with the Lord and his people (Ezek. 18:23, 32; 33:11; Matt. 18:10-14).

Let us be saddened by this event and warned to fear the Lord and live close to him and his Word. Today we clearly hear God's voice of judgment. Let us not harden our hearts (Ps. 95:8), but place ourselves under the discipline of our Master, who lovingly and firmly renews our lives through the ministry of his Word and Spirit.

Since we are assured that the Lord forgives, let us together call on him, confessing our sin and pleading for mercy (Ps. 130).

[To be concluded with an appropriate prayer.]

This form, adopted for use by Synod of 1982, includes the three announcements that the Church Order requires before excommunication takes place.