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
Äàòà