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Model A.1

PANITIA PENGAWAS PEMILIHAN UMUM

KECAMATAN KONGBENG
Sekretariat : Jalan Wijaya Kusuma Desa Marga Mulia Kecamatan Kongbeng
Email : panwaslukongbeng2017@gmail.com

PENERIMAAN LAPORAN
Nomor : ……/LP/PILGUB/KB/2017

Kecamatan Kongbeng

1. Pelapor
a. Nama : .........................................................................
b. NomorI dentitas (KTP/SIM) : .........................................................................
c. Tempat/Tgllahir : .........................................................................
d. Jenis Kelamin : .........................................................................
e. Pekerjaan : .........................................................................
f. Kewarganegaraan : .........................................................................
g. Alamat : .........................................................................
RT/RW …………. Desa/Kel …………………...
Kecamatan ………………………………………
Kabupaten ………………………………………
h. No Telp/HP : .........................................................................
i. Fax : .........................................................................
j. E-Mail : .........................................................................

2. Peristiwa yang dilaporkan :

a. Peristiwa
b. Tempat Kejadian
c. Hari / Tanggal Kejadian
d. Waktu Kejadian
e. Terlapor
f. Alamat Terlapor
g. No. Telp Terlapor
: .........................................................................
...........................................................................
: .........................................................................
: .........................................................................
: .........................................................................
: .........................................................................
: .........................................................................
...........................................................................
: .........................................................................

3. Saksi – Saksi :
a. Nama : .........................................................................
Alamat : .........................................................................
 No. Telp/HP : .........................................................................
b. Nama : .........................................................................
Alamat : .........................................................................
No. Telp/HP : .........................................................................

c. Nama : .........................................................................
Alamat : .........................................................................
No.Telp/HP : .........................................................................

4. Bukti - Bukti
a. …………………………………………………………………………………………..
b. …………………………………………………………………………………………..
c. …………………………………………………………………………………………..
d. …………………………………………………………………………………………..
e. …………………………………………………………………………………………...

5. Uraian singkat kejadian

………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………

Dilaporkan di :
Hari&Tanggal :
Waktu / Jam :

Saya menyatakan bahwa isi laporan ini adalah yang sebenar-benarnya dan saya
bersedia mempertanggungjawabkannya di hadapan hukum.

Penerima Laporan Pelapor

……………………… ……………………….