申请人：                                                                       
                                                                                    

被申请人：                                                                  

请求事项：
　　１、                                                                  

事实和理由：                                                          

                                                                          特此申请。

　　                此致
                                     
           人民法院
　　
　　                                     申请人：           （签字或者盖章）
　　                                       

        年      月      日

附：