自诉人：_______________________________________________________

被告人：_______________________________________________________

案由：_________________________________________________________

诉讼请求：

追究刑事责任要求民事赔偿事实与理由：___________________________________________________

______________________________________________________________

______________________________________________________________

_________________________________________

证据和证据来源，证人姓名和住所：________________________________

______________________________________________________________

______________________________________________________

此致

____________人民法院

自诉人：代书人：

年月日

附：本诉状副本______份