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Lampiran Perbawaslu No 14 - 2012

Lampiran Perbawaslu No 14 - 2012

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Published by Hudayana Purwanto

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Published by: Hudayana Purwanto on Sep 27, 2013
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- 12 -
Lampiran Peraturan Badan Pengawas Pemilihan UmumNomor : 14 Tahun 2012Tanggal : 24 Oktober 2012Model B.1-DDPENERIMAAN LAPORAN
Nomor :
….
/LP/
PILEG/BULAN 
 /TAHUN 
.
 Nasional
: ………….
 Provinsi
: ………….
 Kabupaten/Kota
: ………….
 Kecamatan :
………….
 Desa/Kelurahan
: ………….
 
1. Pelapor
 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 dilaporkan
a.
 
Peristiwa : ...............................................................b.
 
 Tempat Kejadian : ...............................................................c.
 
Hari dan Tanggal Kejadian : ..............................................................d.
 
Waktu Kejadian : ..............................................................e.
 
 Terlapor : ..............................................................f.
 
Alamat Terlapor** : ..............................................................g.
 
No. Telp/HP Terlapor : ..............................................................
3. Saksi
 – 
saksi
 1.
 
Nama : .................................................................................Alamat** : .................................................................................No. Telp/Hp : .................................................................................2. Nama : .................................................................................Alamat** : .................................................................................No. Telp/Hp : .................................................................................3. Nama : .................................................................................Alamat** : .................................................................................No. Telp/Hp : .................................................................................
 
- 13 -
CAP
4. Bukti-Bukti*
:a.
 
...........................................................................................................b.
 
...........................................................................................................c.
 
...........................................................................................................d.
 
...........................................................................................................e.
 
...........................................................................................................
5. Uraian singkat kejadian:
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............ 
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............ 
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............ 
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............
…………………………………………………………………………………….
............ 
…………………………………………………………………………………….
............Dilaporkan di :Hari dan Tanggal :Waktu :Saya menyatakan bahwa isi laporan ini adalah yang sebenar-benarnya dansaya bersedia mempertanggungjawabkannya di hadapan hukum.
Penerima Laporan
…………………..
 
Pelapor
………………………
 
Diteruskan ke Pengawas Pemilu
Hari dan Tanggal :Penerima :
Keterangan:
*
tidak wajib diisi.
**
 jika alamat tempat tinggal lengkap tidak diketahui, cukup disebutkan dusun/desa/kelurahan terlapor.
 
- 14 -
Model B.2-DD
FORMULIR TEMUAN
Nomor
:….
/TM/
PILEG/BULAN 
 /TAHUN 
.
 
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 dilaporkan
a.
 
Peristiwa : ...............................................................b.
 
 Tempat Kejadian : ...............................................................c.
 
Hari dan Tanggal Kejadian : ..............................................................d.
 
Waktu Kejadian : ..............................................................e.
 
 Terlapor : ..............................................................f.
 
Alamat Terlapor** : ..............................................................g.
 
No. Telp/HP Terlapor : ..............................................................
3.
Saksi
 – 
saksi
 1.
 
Nama : .................................................................................Alamat** : .................................................................................No. Telp/Hp : .................................................................................2.
 
Nama : .................................................................................Alamat** : .................................................................................No. Telp/Hp : .................................................................................

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