刑事附带民事诉状自诉人:_______________________________________________________被告人:_______________________________________________________案由:_________________________________________________________诉讼请求:追究刑事责任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