原告_________________________性别________________________出生日期___________________________
                  民族_________________________职业________________________住所地址___________________________
                  被告_________________________性别________________________出生日期___________________________
                  民族_________________________职业________________________住所地址___________________________
                  诉讼请求
                  ____________________________________________________________________________________________
                  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：本诉状副本__份
                  起诉人_________
                  ____年__月__日