刑事附带民事诉状

    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