原告：____________________________________
委托代理人：______________________________
被告：____________________________________
法定代表人：______________________________
诉讼请求：
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________
事实和理由是：
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
__________________
此致
______人民法院
具状人：_____________
委托代理人：_________
_____年_____月_____日
