行政起诉状(公民提起行政诉讼)
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