行政赔偿起诉状

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