第　　页共　　页

    案由：__________________________
　　当事人：________________________
　　陈述、申辩人：__________________
　　联系方式：______________________
　　陈述和申辩时间：______年_____月____日____时____分至_____时_____分
　　陈述和申辩地点：_________________________________________________
　　承办人：____________________________记录人：_____________________

　　陈述和申辩内容   

    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________
    ______________________________________________________________________________________________

陈述申辩人签字：___________
承办人签字：_______________
记录人签字：_______________
_______年_______月_______日