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