人民法院：

    你院受理的                            与我

   一案，依照法律规定，特委托

  （性别：          年龄：      工作单位：

   职业：          住址：                              ）为我的诉讼代理 人。

        委托事项和权限如下：

                                                 委托人：

                                                                                                                        受委托人：

                                                                                                                       年    月    日