行政起诉状样式

原告：_________________________________________________________

被告：_________________________________________________________

案由：_________________________________________________________

诉讼请求：_____________________________________________________

事实与理由：____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

证据和证据来源，证人姓名和住址：_______________________________

此致

_____________人民法院

起诉人：____________

______年______月______日

附：本诉状副本_______份。