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