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当 事 人________________________ 男、女______年______月_____日出生 民 族__________ （法定代表人）_____________ 职 业（职务）___________ 住 址_______________________________________________________________ 案 由_______________________________________________________________ 当事人请求和陈述事实________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 律师意见____________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 记录日期 当事人签名