反诉人（本诉被告）__________________________________________________________________
                  被反诉人（本诉原告）________________________________________________________________
                  反诉请求
                  ____________________________________________________________________________________
                  事实与理由
                  ____________________________________________________________________________________
                  证据和证据来源，证人姓名和住址
                  ____________________________________________________________________________________

                  此致
                  _________人民法院

                  附：本反诉状副本__份
                  反诉人_________
                  _____年__月__日