事附带民事诉讼 
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