原告           性别        出生年月            电话        

身份证号码                 住址                             

被告                       法定代表人         电话         

地址                       送达地址                         

诉讼请求：

1、                                                       

2、                                                       

3、                                                       

4、                                                       

事实与理由：

   此致

            人民法院

具状人：

 　年   月   日