I - Qualificação do autor:

Nome:________________________________________,
Nacionalidade:____________________,
Profissão:___________________________, Idade:___________, Estado
Civil:_______________,
RG:___________________________________,
CPF:__________________________________,
Endereço:________________________________________________________
_______________________________________________________________
_____________________________,
Fones/E-mail:_________________________________________________.
II - Qualificação do réu (usar verso se diversos):
Nome:_____________________________________,
Nacionalidade:_______________________,
Profissão:___________________________, Idade:___________, Estado
Civil:_______________,
RG:___________________________________,
CPF:__________________________________,
Endereço:________________________________________________________
_______________________________________________________________
_____________________________,
Fones/E-mail:____________________________________________.
III – Caso.
Descrever o caso de forma detalhada (dia, hora, fatos, pessoas, testemunhas,
provas):__________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________.

Qual o objetivo buscado com o ingresso da ação judicial?

________________________________.
Declaro para os devidos fins que as informações acima são verdadeiras e correspondem aos
fatos que ocorreram, sob pena de responsabilidade administrativa, civil e criminal.
LOCAL, _______ de ___________ de 20____.
Assinatura: ___________________________.