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No Term Date Time Item Qty Need/Item Sub.

Total/Item Info
ESCALATION PAYMENT
1 * Week 1 Zona 1
1 Asep Supriatna Fam's 13 prs Rp 5,500,000 Rp 5,500,000 done
2 Nujib fam' 5 prs Rp 300,000 Rp 1,500,000 done
3 Endi Fam's 3 prs Rp 300,000 Rp 900,000 done
4 Ook Mubarok Fam's 6 prs Rp 300,000 Rp 1,800,000 done
5 Ajun Fam's 4 prs Rp 300,000 Rp 1,200,000 done
6 Unay Fam's 7 prs Rp 300,000 Rp 2,100,000 done
7 Agus Fam's 4 prs Rp 300,000 Rp 1,200,000 done
8 Hamzah hakim 3 prs Rp 3,500,000 Rp 3,500,000 done
A Sub. Total Rp 17,700,000
2 ** Week 1 Zona 2 till end
1 Radius 20- 40 meter 50 Fam Rp 500,000 Rp 25,000,000 done
2 Radius 40-70 meter 35 fam Rp 500,000 Rp 17,500,000 done
3 warga susulan 11 fam Rp 500,000 Rp 5,500,000 done
B Sub. Total Rp 48,000,000
3 *** Week 2 Society Needs by Proposal
1 Karangtaruna 1 pax Rp 2,000,000 Rp 2,000,000 Bantuan
2 Masyarakat 1 pax Rp 5,000,000 Rp 5,000,000 Bantuan
3 Community Organizatios (ORMAS) 4 pax Rp 500,000 Rp 2,000,000 PP, MANGGALA, BALADEWA, GIBAS,
4 Mesjid 2 pax Rp 1,000,000 Rp 2,000,000 Bantuan
C Sub. Total Rp 11,000,000
4 **** Week 3 Government Coordinations
1 RT 1 pax Rp 750,000 Rp 750,000 done
2 RW 1 pax Rp 750,000 Rp 750,000 done
3 Kadus (Kepala Dusun) 1 pax Rp 1,000,000 Rp 1,000,000 done
4 Babinsa 1 pax Rp 1,000,000 Rp 1,000,000 tentative
5 Babinmas 1 pax Rp 1,000,000 Rp 1,000,000 done
6 SEK CAM 1 pax Rp 1,500,000 Rp 1,500,000 done
7 Kepala Desa 1 pax Rp 6,000,000 Rp 6,000,000 done
8 reskrim 1 pax Rp 1,500,000 Rp 1,500,000 tentative
9 Koramil 1 pax Rp 1,500,000 Rp 1,500,000 tentative
10 Kapolsek 1 pax Rp 2,000,000 Rp 2,000,000 tentative
11 Camat 1 pax Rp 2,500,000 Rp 2,500,000 done
12 Pol PP 1 pax Rp 1,500,000 Rp 1,500,000 done
13 kasi tibmas 1 pax Rp 1,500,000 Rp 1,500,000 done
D Sub. Total Rp 22,500,000
5 * Week 1 Operational Cost
Dimas 1
Ari CME 1 Rp 1,500,000 Rp 1,500,000 fam
Arip 1 Rp 1,500,000 Rp 1,500,000 fam
Galih 1 Rp 8,500,000 Rp 8,500,000 fam
Dian 1 Rp 4,000,000 Rp 4,000,000 fam
Wiwid 1 Rp 7,000,000 Rp 7,000,000 fam
OPS 1 Rp 3,000,000 Rp 3,000,000
E Rp 25,500,000

6 ***** sisa Eskalasi Rp 124,700,000


Escalations Rp 130,000,000 -
F sisa dana Rp 5,300,000

Grand Total Total biaya Eskalasi + Fee sitac


BUKTI TANDA TERIMA TALIKASIH

Lampiran KTP
No. Ket Nama Tanda Tangan
ADA TIDAK
1 ASEP SUPRIATNA
2 NUJIB
3
Warga AJUN JUNAEDI
4 Batas UNAY
5 Lahan OOK MUBAROK
Zona 1
6 AGUS
7 ENDI
8 HAMZAH

1 NUNUNG HASANAH
2 ROHMAN
3 ELIS SUMARTINI
4 OTIH
5 SAMSUDIN
6 DEDE SUJADI
7 ENDANG S
8 SOBAR
9 HAR SOEPIAN
10 TARSIH
11 NENENG
12 DEDI SUPRADI
13 KIRMAN
14 DIAN
15 HAMZAH GOJALI
16 ELLAWATI
17 PERI
18 HERMAN
19 AGUS SUGIAR
20 DADANG
21 YANA
22 ADING
23 DENI SENO ARYANDI
24 OSID
25 SUSI SUSILAWATI
26 TISNA
27 HENDAR
28 MIFTAHULHUDA
29 CAHYA SUMIAT
30 APONG
31 SUPRIATNA
32 SOPANDI
33 ANDRIANTO
34 DEDEH RAHMAWATI
35 H MAMAT
36 ENUNG NURHAYATI
37 SOFI N.
38 ALDA MASDALENA
39 APUD S
40 SAPUDIN
41 KANAH
42 NENENG INDAH
43 WATI
44 RODIAH
45 UJANG
46 NURHASANAH
Warga
47 Radius TISNA H.
48 70 meter AISAH
49 Zona 2 ENUNG
dst.
50 ATIKAH
51 UMEH
52 AFIFAH
53 RENI
54 IJAH KOMARIAH
55 IDIN JAMALUDIN
56 ASEP YUNUS
57 OJAN
58 KOSASIH
59 ADMAD
60 UKA
61 REKSA
62 DADANG
63 USUP S
64 RINA H
65 GUNAWAN
66 ERNA
67 DEDI
68 ADE RAHMAT
69 CUCUN
70 IIS AMELIA
71 ALIAH
72 TRISNA MUKTI
73 PARTI SUPARTI
74 TENI
75 DENI SETIAWAN
76 HENDRA
77 SUMIRAT
78 MARLIAH
79 EMAH
80 AMAS
81 DIDIN
82 OMPON
83 IMAS SURYANI
84 LENA KARTIKA SARI
85 LENI YULIANTI
86 HILMI FITRIANI
87 IWI
88 ADAH
89 INDRI NURHAENI
90 IMIK
91 NIA KURNIASIH
92 VINI FITRIANI
93 EULIS NURLATIPAH
94 ELLAWATI
95 ENDI

Di hadiri dan disaksikan oleh :

Herman
Dimas
Zeppy
Tagor
Share Arip
Ari Cme
Mang
Dzain
Wiwid
SUBMISSION OF FUNDS SITAC PROJECT
No Priority Date Item Qty Sub. Protel Info
ESCALATION PAYMENT
1 *** Zona 1
1 Asep Supriatna Fam's 13 prs Rp 5,000,000
2 Nujib fam' 5 prs Rp 2,500,000
3 Endi Fam's 3 prs Rp 1,500,000
4 Ook Mubarok Fam's 6 prs Rp 3,000,000
batas lahan
5 Ajun Fam's 4 prs Rp 2,000,000
6 Unay Fam's 7 prs Rp 3,500,000
7 Agus Fam's 4 prs Rp 2,000,000
8 Hamzah Fam's 2 prs Rp 3,000,000
A Sub. Total Rp 22,500,000
2 **** Zona 2 till end
1 Radius 20-40 meter 50 Fam Rp 40,000,000
2 Radius 40-70 meter 45 fam Rp 22,500,000
B Sub. Total Rp 62,500,000
3 *** Society Needs by Proposal
1 Karangtaruna 1 pax Rp 2,000,000
2 Masyarakat 1 pax
3 Community Organizatios (ORMAS) 5 pax Rp 3,750,000
C Sub. Total Rp 5,750,000
4 *** Government Coordinations
1 RT 1 pax Rp 1,000,000
2 RW 1 pax Rp 1,000,000
3 Kadus (Kepala Dusun) 1 pax Rp 1,500,000
4 Babinsa 1 pax Rp 2,000,000
5 Babinmas 1 pax Rp 2,000,000
6 Pol. PP 1 pax Rp 2,000,000
7 Kepala Desa 1 pax Rp 8,000,000
8 Koramil 1 pax Rp 5,000,000
9 Kapolsek 1 pax Rp 5,000,000
10 Camat 1 pax Rp 6,000,000
11 perangkat desa 4 pax Rp 4,000,000
D Sub. Total Rp 33,500,000
5 ***** Operational Cost
1 All Activity for 1 Project 1 pax Rp 3,000,000
E Aditional Cost Sitac Team Rp 3,000,000

6 ***
-
F

Grand Total Rp 127,250,000 Total biaya Eskalasi + Fee sitac


Catatan : Rp 130,000,000 Cash By TMR
Rp 2,750,000 SELISIH

-
SUBMISSION OF FUNDS SITAC PROJECT
No Priority Date Item Qty Need/Item
ESCALATION PAYMENT
1 *** Zona 1
1 Asep Supriatna Fam's 1 prs Rp 2,000,000
2 Nujib fam' 1 prs Rp 2,000,000
3 Endi Fam's 1 prs Rp 2,000,000
4 Ook Mubarok Fam's 1 prs Rp 2,000,000
5 Ajun Fam's 1 prs Rp 2,000,000
6 Unay Fam's 1 prs Rp 2,000,000
7 Agus Fam's 1 prs Rp 2,000,000
A Sub. Total
2 **** Zona 2 till end
1 Radius 70 meter 85 Fam Rp 500,000
B Sub. Total
3 *** Society Needs by Proposal
1 Karangtaruna 1 pax Rp 15,000,000

2 Masyarakat 1 pax Rp 12,000,000

3 Community Organizatios (ORMAS) 5 pax Rp 2,000,000

C Sub. Total
4 *** Government Coordinations
1 RT 1 pax Rp 1,000,000
2 RW 1 pax Rp 1,000,000
3 Kadus (Kepala Dusun) 1 pax Rp 2,000,000
4 Babinsa 1 pax Rp 1,500,000
5 Babinmas 1 pax Rp 1,500,000
6 Pol. PP 1 pax Rp 1,500,000
7 Kepala Desa 1 pax Rp 3,000,000
8 Koramil 1 pax Rp 3,000,000
9 Kapolsek 1 pax Rp 3,000,000
10 Camat 1 pax Rp 8,000,000
D Sub. Total
5 ***** Operational Cost
1 All Activity for 1 Project 30% pax Rp 2,500,000
E Aditional Cost Sitac Team

6 *** Fee Sitac


Ops. Cost Sitac
F Sitac Fee Balance

Grand Total
TAC PROJECT
Sub. Total/Item Info
NT

Rp 2,000,000
Rp 2,000,000
Rp 2,000,000
Rp 2,000,000
Rp 2,000,000
Rp 2,000,000
Rp 2,000,000
Rp 14,000,000

Rp 42,500,000
Rp 42,500,000

15,000,000 Pemasangan Tiang Lampu Penerangan


Rp Lapang Voli (Public Facility)

12,000,000 Pengecoran Jalan Akses menuju Site (Public


Rp Access)

10,000,000 Penanggulangan ORMAS (Comm.


Rp Organizations Defence)
Rp 37,000,000

Rp 1,000,000
Rp 1,000,000
Rp 2,000,000
Rp 1,500,000
Rp 1,500,000
Rp 1,500,000
Rp 3,000,000
Rp 3,000,000
Rp 3,000,000
Rp 8,000,000
Rp 25,500,000

Rp 750,000 30% DARI Fee Sitac


Rp 750,000

Rp 2,500,000
Rp 750,000 -
Rp 1,750,000

Rp 121,500,000 Total biaya Eskalasi + Fee sitac


No. Ket Nama KTP Eskalasi
1 ASEP SUPRIATNA Rp 4,000,000
2 NUJIB Rp 2,000,000
3 AJUN JUNAEDI Rp 2,000,000
4 Warga Batas Lahan UNAY Rp 2,000,000
5 Zona 1 OOK MUBAROK Rp 2,000,000
6 AGUS Rp 2,000,000
7 ENDI Rp 2,000,000
8 HAMZAH Rp 2,000,000

Total Rp 18,000,000

1 NUNUNG HASANAH Rp 500,000


2 ROHMAN Rp 500,000
3 ELIS SUMARTINI Rp 500,000
4 OTIH Rp 500,000
5 SAMSUDIN Rp 500,000
6 DEDE SUJADI Rp 500,000
7 ENDANG S Rp 500,000
8 SOBAR Rp 500,000
9 HAR SOEPIAN Rp 500,000
10 TARSIH Rp 500,000
11 NENENG Rp 500,000
12 DEDI SUPRADI Rp 500,000
13 KIRMAN Rp 500,000
14 DIAN Rp 500,000
15 HAMZAH GOJALI Rp 500,000
16 ELLAWATI Rp 500,000
17 PERI Rp 500,000
18 HERMAN Rp 500,000
19 AGUS SUGIAR Rp 500,000
20 DADANG Rp 500,000
21 YANA Rp 500,000
22 ADING Rp 500,000
23 DENI SENO ARYANDI Rp 500,000
24 OSID Rp 500,000
25 SUSI SUSILAWATI Rp 500,000
26 TISNA Rp 500,000
27 HENDAR Rp 500,000
28 MIFTAHULHUDA Rp 500,000
29 CAHYA SUMIAT X Rp 500,000
Rp 29,000,000
30 APONG Rp 500,000
31 SUPRIATNA Rp 500,000
32 SOPANDI Rp 500,000
33 ANDRIANTO Rp 500,000
34 DEDEH RAHMAWATI Rp 500,000
35 H MAMAT Rp 500,000
36 ENUNG NURHAYATI Rp 500,000
37 SOFI N. Rp 500,000
38 ALDA MASDALENA Rp 500,000
39 APUD S Rp 500,000
40 SAPUDIN Rp 500,000
41 KANAH Rp 500,000
42 NENENG INDAH Rp 500,000
43 WATI Rp 500,000
44 RODIAH Rp 500,000
45 UJANG Rp 500,000
46 NURHASANAH Rp 500,000
47 TISNA H. Rp 500,000
Warga Radius 70
48 AISAH Rp 500,000
meter
49 ENUNG Rp 500,000
50 ATIKAH Rp 500,000
51 UMEH Rp 500,000
52 AFIFAH Rp 500,000
53 RENI Rp 500,000
54 IJAH KOMARIAH Rp 500,000
55 IDIN JAMALUDIN Rp 500,000
56 ASEP YUNUS Rp 500,000
57 OJAN Rp 500,000
58 KOSASIH Rp 500,000
59 ADMAD Rp 500,000
60 UKA Rp 500,000
61 REKSA Rp 500,000
62 DADANG Rp 500,000
63 USUP S Rp 500,000
64 RINA H Rp 500,000
Rp 6,000,000
65 GUNAWAN Rp 500,000
66 ERNA Rp 500,000
67 DEDI Rp 500,000
68 ADE RAHMAT Rp 500,000
69 CUCUN Rp 500,000
70 IIS AMELIA Rp 500,000
71 ALIAH Rp 500,000
72 TRISNA MUKTI X Rp 500,000
73 PARTI SUPARTI Rp 500,000
74 TENI Rp 500,000
75 DENI SETIAWAN Rp 500,000
76 HENDRA Rp 500,000
Rp 6,000,000
77 SUMIRAT Rp 500,000
78 MARLIAH Rp 500,000
79 EMAH Rp 500,000
Rp 6,000,000

80 AMAS Rp 500,000
81 DIDIN Rp 500,000
82 OMPON Rp 500,000
83 IMAS SURYANI Rp 500,000
84 LENA KARTIKA SARI X Rp 500,000
85 LENI YULIANTI X Rp 500,000
86 HILMI FITRIANI X Rp 500,000
87 IWI X Rp 500,000
88 ADAH X Rp 500,000
89 INDRI NURHAENI X Rp 500,000 Rp 6,500,000
90 IMIK Rp 500,000
91 NIA KURNIASIH X Rp 500,000
92 VINI FITRIANI X Rp 500,000
93 EULIS NURLATIPAH Rp 500,000
94 ELLAWATI Rp 500,000
95 ENDI X Rp 500,000

Total Rp 47,500,000

Sub. Total Rp 65,500,000


ESKALASI Rp 95,000,000 -
Selisih Rp 29,500,000
Herman Rp 3,000,000
Dimas Rp 3,000,000
Zeppy Rp 2,000,000
Tagor Rp 2,000,000
Share Arip Rp 2,000,000 ESKALASI
Ari Cme Rp 2,000,000
Mang Rp 5,000,000
Dzain Rp 5,000,000
Wiwid Rp 5,000,000
Rp 500,000
No Term Date Time Item Qty
ESCALATION PAYMENT
1 * Week 1 Zona 1
1 Asep Supriatna Fam's 1 prs
2 Nujib fam' 1 prs
3 Endi Fam's 1 prs
4 Ook Mubarok Fam's 1 prs
5 Ajun Fam's 1 prs
6 Unay Fam's 1 prs
7 Agus Fam's 1 prs
A Sub. Total
2 ** Week 1 Zona 2 till end
1 Radius 20- 40 meter 50 Fam
2 Radius 40-70 meter 35 fam
B Sub. Total
3 *** Week 2 Society Needs by Proposal
1 Karangtaruna 1 pax

2 Masyarakat 1 pax

3 Community Organizatios (ORMAS) 5 pax

C Sub. Total
4 **** Week 3 Government Coordinations
1 RT 1 pax
2 RW 1 pax
3 Kadus (Kepala Dusun) 1 pax
4 Babinsa 1 pax
5 Babinmas 1 pax
6 Pol. PP 1 pax
7 Kepala Desa 1 pax
8 Koramil 1 pax
9 Kapolsek 1 pax
10 Camat 1 pax
D Sub. Total
5 * Week 1 Operational Cost
1 All Activity for 1 Project 30% pax
E Aditional Cost Sitac Team

6 ***** Week 4 Fee Sitac


End of Distric Recommendation Letter Ops. Cost Sitac
F Sitac Fee Balance

Grand Total
Need/Item Sub. Total/Item Info
ATION PAYMENT

Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Sub. Total Rp 35,000,000

Rp 800,000 Rp 40,000,000
Rp 500,000 Rp 17,500,000
Sub. Total Rp 57,500,000

15,000,000 Pemasangan Tiang Lampu Penerangan


Rp 15,000,000 Rp Lapang Voli (Public Facility)

12,000,000 Pengecoran Jalan Akses menuju Site (Public


Rp 12,000,000 Rp Access)

10,000,000 Penanggulangan ORMAS (Comm.


Rp 2,000,000 Rp Organizations Defence)
Sub. Total Rp 37,000,000

Rp 1,000,000 Rp 1,000,000
Rp 1,200,000 Rp 1,200,000
Rp 2,000,000 Rp 2,000,000
Rp 2,000,000 Rp 2,000,000
Rp 2,000,000 Rp 2,000,000
Rp 2,000,000 Rp 2,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 5,000,000 Rp 5,000,000
Rp 10,000,000 Rp 10,000,000
Sub. Total Rp 35,200,000

Rp 5,000,000 Rp 1,500,000 30% DARI Fee Sitac


Aditional Cost Sitac Team Rp 1,500,000

Fee Sitac Rp 5,000,000


Ops. Cost Sitac Rp 1,500,000 -
Sitac Fee Balance Rp 3,500,000

Grand Total Rp 169,700,000 Total biaya Eskalasi + Fee sitac

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