申请人：________________________    

申请事由：____________________________________________________    

事实与理由：__________________________________________________    

_____________________________________________________________    

提供证据：_____________________________________________________    

______________________________________    

此致    

________人民法院    

申请人：    

 日   月  年    

附：    

1、本申请书副本________份    

2、证据______份    

3、证人姓名_______，住址__________