申诉人：

申诉人因__________一案，对__________人民法院______年______月______日(__________)__________字第__________号民事判决(或裁定)，提出申诉。

请求事项：________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

事实与理由：______________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

此致

________人民法院

申诉人：__________

____年____月____日

附：

1．原审民事判决书(或裁定书)________份；

2．证据材料________份。