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[Bahan Hafalan] Perbawaslu_2_th_2012 Ttg Tata Cara Pelaporan_lampiran

[Bahan Hafalan] Perbawaslu_2_th_2012 Ttg Tata Cara Pelaporan_lampiran

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Published by: Tongku Baleo Parlindungan on Nov 28, 2012
Copyright:Attribution Non-commercial

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12/04/2012

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11
 
LAMPIRAN IPERATURAN BAWASLU REPUBLIK INDONESIANOMOR 2 TAHUN 2012  TENTANG TATA CARA PELAPORAN DAN PENANGANANPELANGGARAN PEMILIHAN UMUM KEPALA DAERAHDAN WAKIL KEPALA DAERAH
BENTUK DAN JENIS FORMULIR PELAPORAN PELANGGARANPEMILU KEPALA DAERAH DAN WAKIL KEPALA DAERAHModel A-1 KWKPENERIMAAN LAPORAN
Nomor : ..................................Nasional
: ………………….…….
 Provinsi
: …………………….….
 Kabupaten/Kota
: ………………….…….
 Kecamatan
: ………………….…….
 Desa/Kelurahan
: ………………….…….
 
1. Pelapor
a.
 
Nama :...............................................................b.
 
Nomor Identitas(KTP/P
aspor/SIM): ……………………………….
................c.
 
 Tempat/Tgl Lahir : ..............................................................d.
 
 Jenis Kelamin :...............................................................e.
 
Pekerjaan :...............................................................f.
 
Kewarganegaraan :...............................................................g.
 
Alamat :...............................................................h.
 
No.Telp/HP :...............................................................i.
 
Fax : .............................................................. j.
 
E-mail :...............................................................
2. Peristiwa yang dilaporkan
a. Peristiwa :...............................................................b. Tempat Kejadian :...............................................................c. Waktu Kejadian :...............................................................d. Siapa: 1) Terlapor :...............................................................2) Korban :...............................................................e. Alamat Terlapor :...............................................................
3. Saksi
 – 
saksi
1. Nama : .....................................................................Alamat : .....................................................................2. Nama : .....................................................................Alamat : .....................................................................3. Nama : .....................................................................Alamat : .....................................................................
4. Bukti-bukti
:a. ..................................................................................................................b. ..................................................................................................................c. ..................................................................................................................d. ..................................................................................................................e. ..................................................................................................................
 
 
12
 
5. Uraian singkat kejadian :
…………………………………………………………………………….
 
…………………………………………………………………………….
 
…………………………………………………………………………….
 Dilaporkan di :Hari/Tgl/Jam :
Saya menyatakan bahwa isi laporan ini adalah yang sebenar-benarnya dan saya bersedia mempertanggungjawabkannya di hadapan hukum.
Pelapor,
…………………..
 
Penerima Laporan,
.................................
 
 
13
 
Model A-1.1 KWKFORMULIR TEMUAN
Nomor : ..........................Nasional
: ………………….…….
 Provinsi
: …………………….….
 Kabupaten/Kota
: ………………….…….
 Kecamatan
: ………………….…….
 Desa/Kelurahan
: ………………….…….
 
1. Data Pengawas
a.
 
Nama : ..............................................................b.
 
Nomor Identitas (KTP/Paspor/SIM)
:……………………….
..................c.
 
 Tempat/Tgl Lahir : ..............................................................d.
 
 Jenis Kelamin :........................................................e.
 
Pekerjaan : ..............................................................f.
 
Kewarganegaraan : ..............................................................g.
 
Alamat : ..............................................................h.
 
No.Telp/HP : ..............................................................i.
 
Fax : .............................................................. j.
 
E-Mail : ..............................................................
2. Peristiwa yang ditemukan
a. Peristiwa :...............................................................b. Tempat Kejadian :...............................................................c. Waktu Kejadian :...............................................................d. Siapa: 1) Pelaku :...............................................................2) Korban :...............................................................e. Alamat Pelaku :...............................................................
3. Saksi
 – 
saksi
1. Nama : .....................................................................Alamat : .....................................................................2. Nama : .....................................................................Alamat : .....................................................................3. Nama : .....................................................................Alamat : .....................................................................
4. Bukti-Bukti
:a. ..................................................................................................................b. ..................................................................................................................c. ..................................................................................................................d. ..................................................................................................................e. ..................................................................................................................
5. Uraian singkat kejadian :
…………………………………………………………………………….
 
…………………………………………………………………………….
 
…………………………………………………………………………….
 

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