自诉人：________________

被告人：________________

案由：_________________________________________________________

___________________________________________________________________

诉讼请求：

1. 追究刑事责任

2. 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