________________, dnia _____________
(miejscowość) (data)
Wnioskodawca:
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(imię i nazwisko)
____________________________
(adres: ulica, numer domu, numer mieszkania)
____________________________
(kod pocztowy, miejscowość)
RZECZNIK PRAW OBYWATELSKICH
AL. SOLIDARNOŚCI 77
00-090 WARSZAWA
Treść wniosku:
(przedmiot sprawy: czego sprawa dotyczy, jakie prawa lub wolności zostały naruszone, ewentualne wskazanie sygnatur postępowania)
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Załączniki:
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