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申诉人:
申诉人因__________1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。