BERITA ACARA KEJADIAN

Nomor : - / ..…. /BAK /….... / 20…….

Pada hari ini ............. Tanggal ………. bulan …………….... Tahun …………….. sekitar pukul ........... Wib
saya : .........................................................Jabatan .................................... setelah menerima laporan
tentang .....................................................................................................................................................

Membuat Berita Acara Kejadian sebagai berikut :

Saya telah menerima laporan dari seorang : ..................................................................................

Pekerjaan : ..................................................................................

yang melaporkan bahwa telah terjadinya : ..................................................................................

Saya dengan dibantu oleh : …………………………………….……. telah menangani kasus tersebut dengan
meminta keterangan / memeriksa korban / pelapor , keterangan yang diperoleh sbb :

a. Korban : Nama : .............................................

Umur : …………………….. tahun

Alamat : ........................................................................................................

b. Pelaku : Nama : .............................................

Umur : …………………….. tahun

Alamat : ........................................................................................................

c. Saksi : Nama : .............................................

Umur : …………………….. tahun

Alamat : ..........................................................................................................

d. Kerugian :

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e. Barang Bukti :

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f. Kronologis Kejadian :

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g. Tindakan yang diambil :

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Demikian berita acara pemeriksaan kejadian ini saya buat dengan sebenarnya serta dapat
dipertanggung jawabkan atas kebenarannya , kemudian ditutup dan ditanda tangani pada hari dan
tanggal serta tempat seperti tersebut diatas .

Mengetahui Pembuat Berita Acara

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FOTO TKP / BARANG BUKTI