民事再審申訴狀

申訴人：

申訴人因__________一案，對__________人民法院______年______月______日(__________)__________字第__________號民事判決(或裁定)，提出申訴。

請求事項：________________________________________________________________________________________________________

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事實與理由：______________________________________________________________________________________________________

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此致

________人民法院

申訴人：__________

____年____月____日

附：

1.原審民事判決書(或裁定書)________份;

2.證據材料________份。