Начальнику (директору)

                                                                                                  _____________________                                              

                                                                              (учреждения)       

                                                              ____________________________

                                                                           (фамилия, инициалы  начальника (директора)                                                                                    

                                                    от ___________________

                                                                                             ( Ф.И.О. Заявителя)

                                                      проживающего по адресу:

                                                             _________________________

                                                                                                     контактный телефон:                          

                                                                                              почтовый адрес или электронный

                                                                                       адрес:

ЖАЛОБА

ПРЕДМЕТ ЖАЛОБЫ_______________________________________________________

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ДАТА                                                         ЛИЧНАЯ ПОДПИСЬ  ЗАЯВИТЕЛЯ