被调查人：________________________调查人：__________________________调查目的：为_______________

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

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被调查人________(签名或盖章)

在场见证人______(签名或盖章)

________年________月________日