.......................................

(miejscowość, data)

Wojewódzki Sąd Administracyjny

w ....................................................................
za pośrednictwem

..........................................................................
(nazwa organu)

Skarżący: ...................................................
(imię i nazwisko/nazwa)
............................................................................
............................................................................
............................................................................
(adres)

Strona przeciwna: ...........................................

............................................................................
............................................................................
...........................................................................
(nazwa i adres organu)

Wartość przedmiotu sporu: .................................................................

Skarga
na .........................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................

Na podstawie art. 3 § 2 pkt ....., art. 50 § 1 oraz art. 52 § ..... ustawy z dnia 30 sierpnia 2002 r. - Prawo
o postępowaniu przed sądami administracyjnymi (Dz. U. z 2023 r. poz. 259 ze zm.), wnoszę skargę na

..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
zarzucjąc naruszenie: ...........................................................................................................................................
..............................................................................................................................................................................
I wnoszę o: .........................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................

UZASADNIENIE
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................
..............................................................................................................................................................................