O Immaculate, Queen of Heaven and earth, refuge of sinners and our most loving Mother, God has willed to entrust the entire order of mercy to you. I, (name), a repentant sinner, cast myself at ...

and by the whole heavenly court! But since I am still a pilgrim in this vale of tears, receive from me, thy unworthy servant and a poor sinner, the most sincere homage and the most perfect act of ...