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PANWASLU

PANITIA PENGAWAS PEMILIHAN UMUM


KABUPATEN PANDEGLANG
Sekretariat : Jln. Ciwasiat No. 21 Kecamatan Pandeglang – Kabupeten Pandeglang
Website : www.panwaslupdg.com e-mail : panwas.pdg2017@gmail.com

LAPORAN HASIL PENGAWASAN PEMILU

I. Data Pengawas Pemilihan :


Tahapan yang diawasi : ..............................................................
Nama Pelaksana Tugas Pengawasan : ..............................................................
Jabatan1 : ..............................................................
Nomor Surat PerintahTugas : ..............................................................
Alamat : ..............................................................

II. Kegiatan Pengawasan :


1. Kegiatan I
a. Bentuk : ..............................................................
b. Tujuan : ..............................................................
c. Sasaran : ..............................................................
d. Waktu Dan Tempat : ..............................................................

2. Kegiatan II
a. Bentuk : ..............................................................
b. Tujuan : ..............................................................
c. Sasaran : ..............................................................
d. Waktu Dan Tempat : ..............................................................

III. Uraian Singkat Hasil Pengawasan :


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IV. Informasi Dugaan Pelanggaran2:


1. Peristiwa
a. Peristiwa : ..............................................................
b. Tempat Kejadian : ..............................................................
c. Waktu Kejadian : ..............................................................
d. Pelaku : ..............................................................
e. Alamat : ..............................................................

1
Disesuaikan dengan Pengawas di masing-masing tingkatan
2
Diisi bila hasil pengawasan menunjukkan adanya dugaan pelanggaran

1
PANWASLU
PANITIA PENGAWAS PEMILIHAN UMUM
KABUPATEN PANDEGLANG
Sekretariat : Jln. Ciwasiat No. 21 Kecamatan Pandeglang – Kabupeten Pandeglang
Website : www.panwaslupdg.com e-mail : panwas.pdg2017@gmail.com

2. Saksi– saksi
a. Nama : ..............................................................
Alamat : ..............................................................
b. Nama : ..............................................................
Alamat : ..............................................................

3. Alat Bukti :
a. ..............................................................
b. ..............................................................
c. ..............................................................
d. ..............................................................

4 . Barang Bukti :
a. ..............................................................
b. ..............................................................
c. ..............................................................
d. ..............................................................

5 . Uraian singkat Dugaan Pelanggaran :


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Pandeglang, .......................................

Pelaksana Tugas,

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