被调查人：________________________
调查人：__________________________
调查目的：为____________________案
时间：____________________________
地点：____________________________
记录人：__________________________
在场见证人：______________________
笔录内容
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
被调查人________(签名或盖章)
在场见证人______(签名或盖章)
________年________月________日
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