人民调解协议书

编号：                   
当事人（自然人姓名、性别、年龄、民族、职业、单位或住址，法人及社会组织的名称、地址、法定代表人姓名和职务）：
                                                                      
                                                                      
                                                                      
纠纷简要情况：                                                        
                                                                      
                                                                      
                                                                       
经调解，自愿达成如下协议：                                            
                                                                      


                                                                      
                                                                      
履行协议的方式、地点、期限：                                     
                                                                 
                                                                  
                                                                  
   本协议一式        份，当事人、人民调解委员会、所属街道司法所各执一份。
   当事人（签名或盖章）                                              
                                                                      
调解员（签名）                                                     
                   （人民调解委员会盖章）
                                                   年       月     日