委托代理人______________________________ 联系方式_____________________________________
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对方当事人____________________________________________________________________________
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申诉请求______________________________________________________________________________
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事实和理由____________________________________________________________________________
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______________________________________________________________________________________ 此致_____________人民检察院年 月 日 申诉人签名（盖章）：附证据材料：民事（行政）案件申诉书制作说明
