原告姓名_________________性别_______________出生日期____________民族___________
                  籍贯____职业___________住所地________________________________________电话___________
                  被告行政机关名称____________________________________________________________________
                  事实与理由
                  ____________________________________________________________________________________
                  法定代表人姓名_______________________________________________________职务___________
                  诉讼请求
                  ____________________________________________________________________________________
                  事实与理由
                  ____________________________________________________________________________________
                  证据、证据来源和证明对象，证人姓名、年龄、身份证件等
                  ____________________________________________________________________________________
                  此致
                  __________人民法院
                  附：本诉状副本__份
                  起诉人________
                  ____年__月__日