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行政起诉状

行政起诉状

 

原 告         性别    民族        出生年月日              

籍贯                 现住址                                

联系电话                            

 

被 告                                                      

法定代表人           职务          

住址                                                       

联系电话                              

 

第三人         性别    民族        出生年月日              

籍贯                 现住址                                

联系电话                            

 

案由:                    

 

诉讼请求:

  1.                                                                  

 2.                                                                    

 3.                                                                   

  4.                                                                     

 

事实与理由:

                                                                     

                                                                       

                                                                      

                                                                      

                                                                      

                                                                      

                                                                      

 

证据和证据来源:(证人的姓名和住址)

                                                                      

                                                                      

 

    此致

市  区人民法院

 

附:本起诉状副本   

                                     

 

起诉人             

                                             年   月   日