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。