LAMPIRAN:

PERATURAN BADAN PENGAWAS

PEMILIHAN UMUM REPUBLIK INDONESIA
NOMOR 11 TAHUN 2014
TENTANG
PENGAWASAN PEMILIHAN UMUM

Formulir Model A

LAPORAN HASIL PENGAWASAN PEMILU

I. Data Pengawas Pemilihan

Tahapan yang diawasi : DEKLARASI PENGURUS DPC SEDULUR
JOKOWI KAB. SRAGEN
Nama Pelaksana Tugas Pengawasan : ASMURI, SE
Jabatan : Pengawas pemilihan Desa Purworejo
Nomor Surat Perintah Tugas : ...... / Bawaslu.Prov-JT.24-10 / PM.05 / I / 2018
Alamat Dukuh Ngabean RT 11, Desa Purworejo, Kec.
Gemolong
II. Kegiatan Pengawasan:
1. Kegiatan
a. Bentuk : Deklarasi Pengurus DPC Sedulur Jokowi Kab.
Sragen
b. Tujuan : Pengawasan
c. Sasaran : Peserta Undangan – Masyarakat
d. Waktu Dan Tempat : Minggu, 20 Oktober 2018/ Pukul 20.25 s/d
22.00 / Tempat di Rumah Makan Hj. Sumi Resto
Ayam, Jl. Solo - Purwodadi Km.22, Gemolong,
Sragen
2. Kegiatan
a. Bentuk : ...............................................................................
b. Tujuan : ...............................................................................
c. Sasaran : ...............................................................................
d. Waktu Dan Tempat : ...............................................................................

III. Uraian Singkat Hasil Pengawasan

Pelaksanaan Pengukuhan dan Deklarasi Pengurus DPC Sedulur Jokowi Kab. Sragen
Panitia : Bp. Totok, dihadiri kurang lenih 400 orang.
Hadir dalam kegiatan sbb :
1. Prof. Dr. Paiman Raharjo (Ketua DPP Pusat)
2. Ir. H. Tri Agus Bayu Seno (Caleg DPR RI Partai Hanura)
3. Tri Kuntadi (Ketua DPD Jawa Tengah)
4. Sadiman Subur (Ketua DPC Kab. Sragen)
5. Partai Pendukung Jokowi (Makruf Amin)
 IV. Informasi Dugaan Pelanggaran
1. Peristiwa
a. Peristiwa : ...............................................................................
b. Tempat Kejadian : ...............................................................................
c. Waktu Kejadian : ...............................................................................
d. Pelaku : ...............................................................................
e. Alamat : ...............................................................................

2. Saksi – saksi
1. Nama : ...............................................................................
Alamat : ...............................................................................
2. Nama : ...............................................................................
Alamat : ...............................................................................
3. Nama : ...............................................................................
Alamat : ...............................................................................

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

4. Barang Bukti
b. : ...............................................................................
b. : ...............................................................................
c. : ...............................................................................

3. Uraian singkat Dugaan Pelanggaran:

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

Sragen, 28 Oktober 2018

Panwaslu Kelurahan / Desa Purworejo
Pelaksana Tugas,

ASMURI, SE

Formulir Model A.1

PENERIMAAN LAPORAN
 Nomor : ....... / LP / PILGUB / .... / 2018
Nasional : Indonesia
Provinsi : Jawa Tengah
Kabupaten/Kota : Sragen
Kecamatan : Gemolong
Desa/Kelurahan : ............................

1. Pelapor
a. Nama : .....................................................................
b. Nomor Identitas (KTP/Paspor/SIM) : .....................................................................
c. Tempat/Tgl Lahir : .....................................................................
d. Jenis Kelamin : .....................................................................
e. Pekerjaan : .....................................................................
f. Kewarganegaraan : .....................................................................
g. Alamat : .....................................................................
h. No. Telp/HP : .....................................................................
i. Fax : .....................................................................
j. E-Mail : .....................................................................

2. Peristiwa yang dilaporkan

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

3. Saksi – saksi
1. Nama : .....................................................................
Alamat : .....................................................................
No. Telp/Hp : .....................................................................

2. Nama : .....................................................................
Alamat : .....................................................................
No. Telp/Hp : .....................................................................

3. Nama
Alamat
No. Telp/Hp

4. Bukti-Bukti
a. ..........................................................................................................................................
b. ..........................................................................................................................................
c. ..........................................................................................................................................
5. Uraian singkat kejadian:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
 ..................................................................................................................................................

Dilaporkan di : Gemolong
Hari dan Tanggal : .................................
Waktu/jam : .................................

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

Penerima Laporan Pelapor

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

Keterangan:
*sesuaikan dengan jenis Pemilu
**tidak wajib diisi.
***jika alamat tempat tinggal lengkap tidak diketahui, cukup disebutkandusun/desa/kelurahan
terlapor.

Formulir Model A2

FORMULIR TEMUAN
Nomor : ....... / LP / PILGUB / .... / 2018
 Nasional : Indonesia
Provinsi : JawaTengah
Kabupaten/Kota : Sragen
Kecamatan : Gemolong
Desa/Kelurahan : ............................

1. Data Pengawas
a. Nama : ...............................................................................
b. Jabatan : ...............................................................................
c. Alamat : ...............................................................................

2. Peristiwa yang dilaporkan

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

3. Saksi – saksi
1. Nama : ...............................................................................
Alamat : ...............................................................................
No. Telp/Hp : ...............................................................................

2. Nama : ...............................................................................
Alamat : ...............................................................................
No. Telp/Hp : ...............................................................................

3. Nama ...............................................................................
Alamat ...............................................................................
No. Telp/Hp ...............................................................................

4. Bukti-Bukti
a. ..........................................................................................................................................
b. ..........................................................................................................................................
c. ..........................................................................................................................................
d. ..........................................................................................................................................
e. ..........................................................................................................................................
f. ..........................................................................................................................................
g. ..........................................................................................................................................

5. Uraian singkat kejadian :

..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
 Pengawas Pemilu,

………………….........

Penerima Temuan,

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

Keterangan:
*sesuaikan dengan jenis Pemilu
**Bidang Penanganan Pelanggaran Pemilu