时间_______年________月_______日________时　报案、控告、举报事由______________________

　　地点________________________________________接谈人_______记录人_______________________

　　报案、控告、举报人_____________________________性别____________年龄___________________

　　工作单位、职务________________________________________________________________________

　　现住址及联系电话______________________________________________________________________

　　报案、控告、举报内容__________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________
　　______________________________________________________________________________________

　　注：本文书用以记载报案、控告、举报犯罪嫌疑人涉嫌的主要问题。在笔录末尾，应由报案、控告、举报人注明对笔录的审阅结果，并签名、盖章。
　　笔录应复制1份，存检察正卷、内卷各1份。