Â____________________ðàéîííûé
                                                          (ãîðîäñêîé)
                                        íàðîäíûé ñóä______________________îáëàñòè
                                                       (êðàÿ, ðåñïóáëèêè)
                                        îò_______________________________________
                                              (ô. è. î. ëèöà, ïîäàþùåãî æàëîáó,
                                        _________________________________________
                                                              àäðåñ)
                                        Îòâåò÷èê:________________________________
                                                       (ô.è.î. ñîòðóäíèêà
                                        _________________________________________
                                                       ìèëèöèè, åãî àäðåñ)
                                        Îòâåò÷èê:________________________________
                                                       (îòäåë (óïðàâëåíèå)
                                        _________________________________________
                                                âíóòðåííèõ äåë, ãäå ðàáîòàåò
                                        _________________________________________
                                                ñîòðóäíèê ìèëèöèè, åãî àäðåñ)
 
                                Æàëîáà
            íà íåïðàâîìåðíîå áåçäåéñòâèå ñîòðóäíèêà ìèëèöèè
                                              
"____"___________19__ ã. ñîòðóäíèê ìèëèöèè_______________________________________
_______________________________________________îòäåëà (óïðàâëåíèÿ) âíóòðåííèõ äåë
_________________________________________________________________________________
                                   (ô. è. î.)
íå îêàçàë ïîìîùü ìíå, ïîñòðàäàâøåìó îò ïðàâîíàðóøåíèÿ, êîòîðîå ïðîèçîøëî ïðè ñëåäó-
þùèõ îáñòîÿòåëüñòâàõ_____________________________________________________________
_________________________________________________________________________________
                     (óêàçàòü ãäå, êîãäà, ïðè êàêèõ îáñòîÿòåëüñòâàõ
_________________________________________________________________________________
                                  ñîâåðøåíî ïðàâîíàðóøåíèå)
è íå ïðåñåê åãî ñîâåðøåíèå.
 ðåçóëüòàòå ñîâåðøåííîãî ïðàâîíàðóøåíèÿ ìíå íàíåñåíû òåëåñíûå ïîâðåæäåíèÿ_______
_________________________________________________________________________________
                      (óêàçàòü êàêèå, ñòåïåíü
_________________________________________________________________________________
                               òÿæåñòè)
 
Òàêæå, ÿ ïîíåñ èìóùåñòâåííûé óùåðá_______________________________________________
                                                  (óêàçàòü, êàêèå
_________________________________________________________________________________
                  ìàòåðèàëüíûå óáûòêè ïîíåñ çàÿâèòåëü îò ïðàâîíàðóøèòåëÿ)
Íåïðàâîìåðíîå áåçäåéñòâèå ðàáîòíèêà ìèëèöèè______________________________________
                                                       (ô. è. î.)
ïîäòâåðæäàþòñÿ ñëåäóþùèì:________________________________________________________
                                      (óêàçàòü ìîòèâû,
_________________________________________________________________________________
                ïî êîòîðûì çàÿâèòåëü ñ÷èòàåò áåçäåéñòâèå ðàáîòíèêà ìèëèöèè
_________________________________________________________________________________
                íåïðàâîìåðíûìè, óùåìëÿþùèìè åãî ïðàâà è çàêîííûå èíòåðåñû)
 
Ìîé ìàòåðèàëüíûé óùåðá ïîäòâåðæäàåòñÿ____________________________________________
                                                        (ïðèâåñòè
_________________________________________________________________________________
                      íåîáõîäèìûå ðàñ÷åòû óùåðáà, êàêèìè äîêóìåíòàìè
_________________________________________________________________________________
                                   îí ïîäòâåðæäàåòñÿ)
 
 ñîîòâåòñòâèè ñî ñò.ñò. 10, 39 Çàêîíà ÐÑÔÑÐ "Î ìèëèöèè", ïðîøó:
 
Ïðèçíàòü áåçäåéñòâèå ñîòðóäíèêà ìèëèöèè__________________________________________
                                                        (ô. è. î.)
ïðè ñîâåðøåíèè ïðàâîíàðóøåíèÿ íåïðàâîìåðíûìè.
Îáÿçàòü âîçìåñòèòü ìíå óùåðá, ïðè÷èíåííûé â ðåçóëüòàòå  ïðàâîíàðóøåíèÿ  â ðàçìåðå
___________________________________________________________________________ðóáëåé.
 
 
Ïðèëîæåíèå:
1. Äîêóìåíòû, ïîäòâåðæäàþùèå íåïðàâîìåðíîå áåçäåéñòâèå ñîòðóäíèêà ìèëèöèè.
2. Äîêóìåíòû, ïîäòâåðæäàþùèå ðàçìåð óùåðáà.
3. 2 êîïèè æàëîáû.
 
Ïîäïèñü
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