Lampiran SE No. 14/44/INTERN tgl.

2 Oktober 2012

Contoh Formulir Identifikasi Calon Penerima Bantuan PSBI

Nama Lembaga Pemohon :

Alamat :
No. Telepon :
Narasumber dan Jabatan :
Usulan Kegiatan :

Kelembagaan
1. Kapan lembaga berdiri?
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2. Jelaskan latar belakang, tujuan dan visi lembaga?
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3. Jelaskan perkembangan lembaga sampai dengan saat ini?
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4. Jelaskan sumber dana lembaga?
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5. Jelaskan pengalaman atau track record kegiatan yang dilaksanakan lembaga?
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6. Jelaskan manfaat keberadaan lembaga bagi masyarakat?
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Kepengurusan / Peserta / Anggota

1. Jelaskan struktur organisasi, jumlah dan siapa yang menjadi pengurus lembaga?
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2. Jelaskan latar belakang (sosial ekonomi dan pendidikan) pengurus / peserta /
anggota?
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3. Bagaimana tingkat keaktifan pengurus pada kegiatan di lembaga?
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Kegiatan
1. Kegiatan apa yang akan dilaksanakan dan membutuhkan bantuan dari Bank
Indonesia?
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2. Apa latar belakang dan tujuan dilaksanakannya kegiatan tersebut?
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3. Siapa target penerima manfaat kegiatan?
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4. Berapa rincian biaya / anggaran kegiatan tersebut?
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5. Darimana sumber pendapatan untuk melaksanakan kegiatan tersebut?
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