编号：坝调2011第 号

人民调解协议书

申请人：

被申请人：

本案当事人自愿将纠纷申请

经审查，本案符合人民调解委员会受理

条件；在人民调解员 主持调解下，达成本协议。

基本案情：

协议内容：

1

履行协议的方式： 履行协议的地点： 履行协议的期限： 本协议经本案当事人签字、盖章，人民调解员签名，人民调解委

员会盖章即发生法律约束力。当事人应严格遵守、自觉履行，不得擅自变更或者解除本调解协议。

本协议一式 份，由当事人各执一份，人民调解委员会留存

一份，具有同等效力。

当事人（签字或盖章）

调解员（签字） 人民调解委员会（盖章）

签订日期 年 月 日

2

 

第二篇：20xx年人民调解协议书格式

                  人民调解委员会

调解卷宗

卷宗类别：                           

卷    名：                          

年    度：                          

人民调解员：                           

调解日期：                           

立 卷 人：                           

立卷日期：                           

保管期限：                           

备    注：                          

卷 宗 内 目 录

人民调解申请书

    申请人姓名                性别     民族     年龄     

职业或职务                     联系方式                    

单位或住址                                                  

被申请人姓名               性别     民族     年龄         

职业或职务                     联系方式                

单位或住址                                               

纠纷简要情况：                                         

                                                        

                                                        

                                                           

                                                          

                                                         

                                                          

当事人申请事项：

1、                                                   

2、                                                   

3、                                                   

人民调解委员会已将申请人民调解的相关规定告知我，现自愿申请人民调解委员会进行调解。

申请人（签名盖章或按指印）         年       月         日

人民调解受理纠纷登记表

               年     月     日，人民调解委员会依当事人申请（人民调解委员会主动调解），调解                     与

                      之间的纠纷。

纠纷类型：                                           

案件来源：①当事人申请书；②人民调解委员会主动调解

纠纷简要情况：                                       

                                                          

                                                          

                                                         

                                                          

                                                            

                                                         

                                                          

                                                          

                                                            

     当事人（签名）                 

     登记人（签名）                 

                                         人民调解委员会

                                   年     月      日

人民调解调查记录

时间：                      地点：                             

事由：                      参加人：                               

被调查人：                                                

                                                         

记录:                                                         

                                                                 

                                                                 

                                                                

                                                                

                                                                  

                                                                

                                                                 

                                                        

                                                          

                                                         

被调查人（签名）                    

调 查 人（签名）                    

记 录 人（签名）                    

人民调解记录

时间：                        地点：                              

事由：                        参加人：                              

当事人：                                                  

                                                          

记录:                                                         

                                                                 

                                                                  

                                                                

                                                                

                                                                  

                                                                

                                                                   

                                                                   

                                                                       

                                                                   

当事人（签名）                                 

调解员（签名）                                  

参加人（签名）                                  

记 录 人（签名）                                

                                年     月     日

人民调解协议书

                                    编号：                 

当事人姓名              性别      民族      年龄     

职业或职务                  联系方式                     

单位或住址                                                      

当事人姓名               性别    民族     年龄        

职业或职务                   联系方式                        

单位或住址                                                      

纠纷主要事实、争议事项：                                     

                                                                

                                                                

                                                                

经调解，于    年   月   日达成如下协议：                                   

                                                                

                                                                 

                                                                

本协议一式          份，当事人、人民调解委员会各持一份。

当事人（签名盖章或按手印）                      

当事人（签名盖章或按手印）                      

人民调解员（签名）                               

记录人（签名）                                   

     

               人民调解委员会       年   月    日

人民调解协议书

                                    编号：                 

当事人姓名              性别      民族      年龄     

职业或职务                  联系方式                     

单位或住址                  身份证号码                            

当事人姓名              性别    民族     年龄        

职业或职务                  联系方式                        

单位或住址                  身份证号码                           

当事人姓名              性别    民族     年龄        

职业或职务                  联系方式                    

单位或住址                 身份证号码                 

当事人姓名              性别    民族     年龄        

职业或职务                 联系方式                      

单位或住址                 身份证号码                

纠纷主要事实、争议事项：                                    

                                                                

                                                                 

                                                        

                                                                                                                            

                                                                

                                                        

                                                                                                                           

                                                                

                                                         

经调解，于    年   月   日达成如下协议：                                  

                                                                

                                                                 

                                                                                                                          

                                                                

                                                        

                                                                                                                           

                                                                

                                                                                                                         本协议一式          份，当事人、人民调解委员会各持一份。

当事人（签名、盖章或按手印）：                              

当事人（签名、盖章或按手印）：                               

参加人（签名、盖章或按手印）：                             

人民调解员（签名）                 记录人（签名）                                   

     

               人民调解委员会（印章）

       年   月    日

人民调解口头协议登记表

                                    编号：                 

当事人姓名              性别      民族      年龄     

职业或职务                  联系方式                     

单位或住址                  身份证号码                            

当事人姓名              性别    民族     年龄        

职业或职务                  联系方式                        

单位或住址                  身份证号码                      

纠纷主要事实、争议事项：                                    

                                                                 

                                                                

                                                            

经调解，于    年   月   日达成如下协议：                                  

                                                                 

                                                                 

                                                                                                                         

                                                           

履行方式、时限                                               

人民调解员（签名）                                           

                                    人民调解委员会（印章）

                                    年    月    日

人民调解回访记录

回访对象                      调解协议编号                  

回访事由                      回访时间                              

回访情况：                                                      

                                                                

                                                                  

                                                                 

                                                                 

                                                                

                                                                 

                                                                 

                                                                

                                                                   

                                                                

受访人（签名）                    

回访人（签名）：                年    月     日 

                                              人民调解委员会

                                     年       月       日

卷宗情况说明

                                        

                                        

                                         

                                         

                                         

                                         

                                         

                                         

                                        

                                         

                                         

                                         

                                        

                                         

                                        

        立卷人