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
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