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__________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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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。
