自诉人____________性别___出生日期_____________民族____职业___________住所地_________________
                  被告人____________性别___出生日期_____________民族____职业___________住所地_________________
                  案由和诉讼请求
                  ____________________________________________________________________________________________
                  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：本自诉状副本___份
                  自诉人_________
                  ____年__月__日