行政起诉状 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。