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
