附带民事诉讼原告人_____________性别____出生年月日________民族____出生地____________
                  文化程度______职业__________职务___________住址____________________________________
                  附带民事诉讼被告人_____________性别____出生年月日________民族____出生地____________
                  文化程度______职业__________职务___________住址____________________________________
                  诉 讼 请 求
                  ___________________________________________________________________________________
                  事 实 与 理 由
                  ___________________________________________________________________________________
                  证人姓名和住址，其他证据名称、来源
                  ___________________________________________________________________________________
                  此致
                  __________人民法院
                  附：本诉状副本__份
                  附带民事诉讼原告人________
                  ____年__月__日