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