人民调解受理登记表

人民调解受理记录表_____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），经当事人同意，调解_________、_________之间纠纷。纠纷类型：____________________________________案件起源：（1）当事人申请（2）人民调解委员会主动调解纠纷简明情况：______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________当事人（署名）____________________登记人（署名）___________________________________人民调解委员会_______年______月______日备注：此表由人民调解委员会填写人民调解调查统计时间：_______________________地点：_______________________参加人：_______________________被调查人：_______________________记录：______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________调查人（署名）_________________被调查人（署名）__________________记录人（署名）__________________人民调解统计时间：_______________________地点：_______________________当事人：_______________________参加人：_______________________人民调解委员会已将人民调解相关要求通知各方当事人。调解统计：_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________调解结果：1、调解成功；2、调解不成；3、有待继续调解当事人（署名盖章或按指印）__________________当事人（署名盖章或按指印）__________________人民调解员（署名）______________________记录人（署名）__________________________年_____月____日人民调解协议书当事人姓名__________性别________民族_______年纪________职业或职务______________________联络方式___________________单位或住址_________________________________________________当事人姓名__________性别________民族_______年纪________职业或职务______________________联络方式___________________单位或住址_________________________________________________纠纷主要事实、争议事项：_________________________________________________________________________________________________________________________________________________________________________________________________________________经调解，自愿达成以下协议：________________________________________________________________________________________________________________________________________________________________________________________________________________推行协议方式、时限：__________________________________本协议一式______份，当事人、人民调解委员会各持一份。当事人（署名盖章或按指印）_______人民调解（署名）_____当事人（署名盖章或按指印）_______人民调解（署名）_____（人民调解委员会印章)______年_____月______日人民调解口头协议记录表当事人姓名__________性别________民族_______年纪________职业或职务______________________联络方式___________________单位或住址_________________________________________________当事人姓名__________性别________民族_______年纪________职业或职务______________________联络方式___________________单位或住址_________________________________________________纠纷主要事实、争议事项：_________________________________________________________________________________________________________________________________________________________________________________________________________________经调解，自愿达成以下协议：________________________________________________________________________________________________________________________________________________________________________________________________________________推行协议方式、时限：__________________________________当事人（签名）_________________________________人民调解（签名）__________________________________（人民调解委员会印章)______年_____月______日备注：此表由人民调解委员会填写人民调解回访统计当事人_______________________________________调解协议书编号_______________________________回访事由_____________________________________回访时间_____________________________________回访情况：_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________回访人（署名）_______________________人民调解委员会______年_____月_____日卷宗情况说明___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________立卷人____________审核人____________立卷日期年月日人民调解委员会调解卷宗卷名：卷号：人民调解员：调解日期：立卷人：立卷日期：保管期限：备