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["第六號用紙"]
["委      任      書",null,null,null,"年    調字第        號"]
["稱謂","姓名〈或名稱〉","性別","出生日期","國民身分證    統一編號","職業","住所或居所\n〈事務所或營業所〉","連絡電話"]
["委任人"]
["受任人"]
["        茲因與                 間                     調解事件，"]
["委任                       為代裡人，有代為一切調解行為之權，"]
["並有同意調解條件、撤回、捨棄、領取所爭物或選任代理人等特別代"]
["理權。"]
["  此致"]
["       臺中市東勢區調解委員會"]
["            委任人：                          〈簽名或蓋章〉"]
["            受任人：                          〈簽名或蓋章〉"]
["中 華 民 國         年         月         日"]

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