刑事附带民事诉状

      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