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FORMULIR SURAT KUASA KHUSUS (FORM III-P/L DKPP)

BERDASARKAN PERATURAN DKPP NOMOR 3 TAHUN 2017 TENTANG
PEDOMAN BERACARA KODE ETIK PENYELENGGARA PEMILIHAN UMUM

FORM III-P/L DKPP

SURAT KUASA KHUSUS

Pada hari ini ................. tanggal …. bulan .................... tahun ........, saya :
a. Nama : …............................................................
b. Organisasi/Lembaga : ...............................................................
c. Nomor KTP/Identitas lain : ...............................................................
d. Tempat/Tanggal Lahir : ...............................................................
e. Jenis Kelamin : ...............................................................
f. Pekerjaan : ...............................................................
g. Alamat Tinggal dan Kantor : ...............................................................
……………………………………………………..
h. No.Telpon/Selular : ...............................................................
i. Faksimile : …............................................................
j. e-mail : ...............................................................

Memberi Kuasa Khusus Kepada:

a. Nama : …............................................................
b. Nomor KTP/Identitas lain : ...............................................................
c. Tempat/Tanggal Lahir : ...............................................................
d. Jenis Kelamin : ...............................................................
e. Pekerjaan : ...............................................................
f. Alamat Kantor : ...............................................................
g. No.Telpon/Selular : ...............................................................
h. Faksimile : …............................................................
i. e-mail : ...............................................................
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Untuk:
Mengadukan dan/atau melaporkan pelanggaran Kode Etik Penyelenggara
Pemilu yang diduga dilakukan oleh:
Teradu dan/atau Terlapor 1 :
a. Nama : ...............................................................
b. Jabatan : ...............................................................
c. Alamat Kantor : ...............................................................
d. Keterangan lain : ...............................................................
……………………………………………………..

Teradu dan/atau Terlapor 2 :

a. Nama : ...............................................................
b. Jabatan : ...............................................................
c. Alamat Kantor : ...............................................................
d. Keterangan lain : ...............................................................
……………………………………………………..
Teradu dan/atau Terlapor 3 :
a. Nama : ...............................................................
b. Jabatan : ...............................................................
c. Alamat Kantor : ...............................................................
d. Keterangan lain : ...............................................................
……………………………………………………..
Teradu dan/atau Terlapor 4 :
a. Nama : ...............................................................
b. Jabatan : ...............................................................
c. Alamat Kantor : ...............................................................
d. Keterangan lain : ...............................................................
……………………………………………………..
Teradu dan/atau Terlapor 5 :
a. Nama : ...............................................................
b. Jabatan : ...............................................................
c. Alamat Kantor : ...............................................................
d. Keterangan lain : ...............................................................
……………………………………………………..
Teradu dan/atau Terlapor 6 :
a. Nama : ...............................................................
b. Jabatan : ...............................................................
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c. Alamat Kantor : ...............................................................

d. Keterangan lain : ...............................................................
……………………………………………………..
Teradu dan/atau Terlapor 7 :
a. Nama : ...............................................................
b. Jabatan : ...............................................................
c. Alamat Kantor : ...............................................................
d. Keterangan lain : ...............................................................
……………………………………………………..

Demikian Surat Kuasa ini dibuat dengan sebenarnya, dan dipergunakan

seperlunya.

Penerima Kuasa, Pemberi Kuasa,

Materai

....................................... ...........................................