Paraf :

BADAN PEMERIKSA KEUANGAN REPUBLIK INDONESIA

Formulir Isian (Kuesioner)

Pemeriksaan Interim atas Laporan Keuangan
Pemerintah Kabupaten Berau TA 2020
Tentang Dana Bantuan Operasional Sekolah (BOS dan BOSDA)

Pada hari ini, ............................., tanggal .......... Januari 2021, jam................WITA. Berdasarkan Surat Tugas
Badan Pemeriksa Keuangan No. 16/ST/XIX.SMD/01/2021 tanggal 25 Januari 2021 telah dilakukan pengisian
kuesioner tentang Pengelolaan Dana BOS dan BOSDA Tahun Anggaran 2020:

Nama Sekolah : ................................................................................................................

Kecamatan : ................................................................................................................
Kabupaten : ................................................................................................................

Dengan isian formulir secara rinci sebagai berikut.

1. Pengelola BOS dan BOSDA

Tanya : Apakah pengelola BOS dan BOSDA Tahun 2020 sudah ditetapkan dalam Surat Keputusan?
Jawab : .....................................................................................................................................................

Tanya : Sebutkan Surat Keputusan pengelola BOS dan BOSDA yang sudah ditetapkan?
Jawab : a. ................................................................. Nomor..................................................Tanggal

..................................................tentang.................................................................................

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

b. ................................................................. Nomor..................................................Tanggal

..................................................tentang.................................................................................

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

c. ................................................................. Nomor..................................................Tanggal

..................................................tentang.................................................................................

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

Hal. 1 dari 6
 d. ................................................................. Nomor..................................................Tanggal

..................................................tentang.................................................................................

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

2. Pengelolaan BOSNAS

Tanya : Berapa Dana BOSNAS yang telah diterima oleh sekolah selama Tahun Anggaran 2020?
Jawab : Triwulan I sebesar Rp.................................................................................................................

Triwulan II sebesar Rp.................................................................................................................

Triwulan III sebesar Rp................................................................................................................

Triwulan IV sebesar Rp...............................................................................................................

Sehingga penerimaan TA 2020 total sebesar Rp.........................................................................

Tanya : Di rekening apa Dana BOSNAS disimpan?

Jawab : Bank.............................................................................................................................................
Nomor Rekening............................................................. ............................................................
Bank.............................................................................................................................................
Nomor Rekening............................................................. ............................................................
Bank.............................................................................................................................................
Nomor Rekening............................................................. ............................................................
Tanya : Apakah rekening tersebut telah ditetapkan melalui SK Bupati? Jika Ya, SK nomor dan tahun
berapa?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
Tanya : Berapa Saldo rekening tersebut per 1 Januari 2020?

Jawab : .....................................................................................................................................................
.....................................................................................................................................................
Tanya : Berapa Saldo rekening tersebut per 31 Desember 2020?

Jawab : .....................................................................................................................................................
.....................................................................................................................................................
 Tanya : Apakah terdapat jasa giro rekening yang ada di rekening tersebut per 31 Desember 2020? Jika
Ya, berapa nilainya? Apakah disetor ke kasda?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Tanya : Sebutkan Rincian Penggunaan Dana BOSNAS?

Jawab : Belanja Pegawai sebesar Rp........................................................................................................

Belanja Barang sebesar Rp.........................................................................................................
Belanja Modal sebesar Rp............................................................................................................
Sehingga jumlah pengeluaran sebesar Rp....................................................................................
Tanya : Belanja Modal yang berasal dari BOSNAS terdiri dari apa saja?

Jawab : Jenis Aset ......................................................... sebesar Rp........................................................

Jenis Aset ......................................................... sebesar Rp.........................................................
Jenis Aset ......................................................... sebesar Rp........................................................
Jenis Aset ......................................................... sebesar Rp........................................................
Jenis Aset ......................................................... sebesar Rp........................................................
.....................................................................................................................................................
Tanya : Apakah penerimaan dan belanja BOSNAS sudah diajukan untuk disahkan melalui SP3B dan
SP2B?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

3. Penerimaan BOSDA

Tanya : Berapa Dana BOSDA yang telah diterima oleh sekolah selama Tahun Anggaran 2020?
Jawab : Triwulan I sebesar Rp.................................................................................................................

Triwulan II sebesar Rp.................................................................................................................

 Triwulan III sebesar Rp................................................................................................................

Triwulan IV sebesar Rp...............................................................................................................

Sehingga penerimaan TA 2020 total sebesar Rp.........................................................................

Tanya : Di rekening apa Dana BOSDA disimpan?

Jawab : Bank.............................................................................................................................................
Nomor Rekening............................................................. ............................................................
Bank.............................................................................................................................................
Nomor Rekening............................................................. ............................................................
Bank.............................................................................................................................................
Nomor Rekening............................................................. ............................................................
Tanya : Apakah rekening tersebut telah ditetapkan melalui SK Bupati? Jika Ya, SK nomor dan tahun
berapa?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
Tanya : Berapa Saldo rekening tersebut per 1 Januari 2020?

Jawab : .....................................................................................................................................................
.....................................................................................................................................................
Tanya : Berapa Saldo rekening tersebut per 31 Desember 2020?

Jawab : .....................................................................................................................................................
.....................................................................................................................................................
Tanya : Apakah terdapat jasa giro rekening yang ada di rekening tersebut per 31 Desember 2020? Jika
Ya, berapa nilainya?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Tanya : Belanja Modal yang berasal dari BOSDA terdiri dari apa saja?

Jawab : Jenis Aset ......................................................... sebesar Rp........................................................

Jenis Aset ......................................................... sebesar Rp.........................................................
Jenis Aset ......................................................... sebesar Rp........................................................
 Jenis Aset ......................................................... sebesar Rp........................................................
Jenis Aset ......................................................... sebesar Rp........................................................
.....................................................................................................................................................

4. Kewajiban PFK

Tanya : Apakah terdapat kewajiban PFK (PPh, PPN, BPJS, dll) yang ditarik oleh bendahara yang
ditarik oleh bendahara belum disetorkan dan masih berada di rekening BOSNAS dan
BOSDA per 31 Desember 2019? Jika Ya, berupa apa dan sebesar berapa?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Tanya : Apakah terdapat kewajiban PFK TA 2019 tersebut telah disetorkan di TA 2020? Jika Ya,
tanggal berapa?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
Tanya : Apakah terdapat kewajiban PFK (PPh, PPN, BPJS, dll) yang ditarik oleh bendahara yang
ditarik oleh bendahara belum disetorkan dan masih berada di rekening BOSNAS dan
BOSDA per 31 Desember 2020? Jika Ya, berupa apa dan sebesar berapa?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Tanya : Apakah terdapat kewajiban PFK TA 2020 tersebut telah disetorkan di TA 2021? Jika Ya,
tanggal berapa?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................

5. Persediaan

Tanya : Apakah dilakukan stock opname persediaan di akhir TA 2020? Berapa saldo persediaan per
31 Desember 2020?
Jawab : .....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
Tanya : Apakah terdapat gudang persediaan yang dilengkapi dengan kartu stok?
Jawab : .....................................................................................................................................................
 .....................................................................................................................................................

Tanya : Apakah dilakukan pelaporan secara periodik atas persediaan kepada Dinas Pendidikan?

Jawab : .....................................................................................................................................................
.....................................................................................................................................................

Pejabat yang mengisi,

Kepala Sekolah

(..........................................................................)

Bendahara BOSNAS

(..........................................................................)

Bendahara BOSDA

(..........................................................................)

Pengurus Barang/Aset

(..........................................................................)

Kelengkapan Kuesioner:
a. SK Bupati Pengelola BOSNAS dan BOSDA;
b. SK Bupati Penetapan Rekening BOSNAS dan BOSDA;
c. Rekening koran BOSNAS dan BOSDA per 31 Desember 2020;
d. Rekening koran BOSNAS dan BOSDA per tanggal pemeriksaan;
e. Berita Acara stock opname persediaan per 31 Desember 2020;
f. Daftar Aset hasil pengadaan BOSNAS dan BOSDA TA 2020;
g. Bukti setor kewajiban PFK (Pajak) TA 2019 dan 2020.