______人民调解委员会
                   卷      宗

                     卷宗类别：________________________________________

                     卷    名：________________________________________

                     年    度：__________年度    卷号：________________

                     调 解 员：_____________     调解日期：____________

                     立 卷 人：______________    立卷日期：____________

                     保管期限：________________________________________

                     备    注：________________________________________
                               ________________________________________