Simply replace the unfilled areas such as "" and "[date]" with your information.
I've reviewed your request, and I feel I need to be frank with you. While I've seen flashes of brilliance in your work, I'm going to need a more consistent overall effort from you before I can consider a raise.
This isn't a reprimand, so please don't take it that way. Overall I'm happy, and the company is happy, with your work. But to get to the next stage, what we'd like from you is consistency to complement your efforts.
I'm open to discussion on this topic as well. My door is always open.