Jln.

Raya Padang-Lubuk Basung – Pasar sebelah , Nagari Kuranji Hilir Kecamatan Sungai Limau Kabupaten Padang Pariaman Kode Pos.25561
Email : panwascamsungaisariksungailimau@gmail.com

FORMULIR MODEL A
LAPORAN HASIL PENGAWASAN PEMILU

I DATAPENGAWAS
• Nama/Tim Pengawas : ...................................................................

• Jabatan : PTPS ........................................

• Alamat/Domisili : .....................................................
II KEGIATAN
PENGAWASAN
• Tahapan yang : Tahapan Penyerahan C.Pemberitahuan kepada Pemilih
diawasi dalam Pemilihan Gubernur dan Wakil Gubernur,
Bupati dan Wakil Bupati Padang Pariaman Tahun
2020
• BentukPengawasan : Langsung. Tidak Langsung
• Pihak yang diawasi : KPPS

• Waktu dan Tempat

Hari:jumat :
Tanggal:
Bulan:
Tahun: 2020
Waktu/Jam : ( ..............................WIB)
Tempat: ......................................................................
..............
III URAIAN HASIL PENGAWASAN :
Hari ini .......... Desember 2020, saya Atas nama ............................................
,mengawasi ketua kpps benar telah mulai membagikan c pemberitahuan kepada
warga/masyarakat di .................. .mulai dari jam ............. wib - ............. wib. namun tidak
semuanya di bagikan hari ini,karena ada warga yg tidak berada di rumah ketika ketua
kpps menyerahkan c pemberitahuan.dan akan dilanjutkan besok bagi warga yang tidak
ditemukan di rumah pada hari ini.Dan setelah berkoordinasi dengan ketua saya
merekap jumlah Dpt keseluruhan sebanyak:............. Dpt laki-laki: ............. & Dpt
perempuan:....................
nama anggota PTPS:
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2. ........................................................
3. ........................................................
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7..........................................................
.pengawas ptps....................
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Demikianlah hasil pengawasan pembagian C.Pemberitahuan di TPS …. Kenagarian

………………… ini
saya sampaikan, dan dapat dipertanggungjawabkan sebagai hasil pengawasan pemilihan
serentak tahun 2020.

IV DUGAAN PELANGGARAN : a. Ada b. Tidak ada

V INFORMASI DUGAAN PELANGGARAN :
 Tempat Kejadian : -
 Waktu kejadian : -
 Nama pelaku : -
 Status pelaku : -
VI URAIAN SINGKAT DUGAAN PELANGGARAN DAN KETENTUAN DALAM
PERATURAN PERUNDANG-UNDANGAN:
VI SAKSI- SAKSI
I
a. Nama pertama : -
b. Nama kedua : -
c. Nama ketiga : -
VI BUKTI PENDUKUNG
II

....................................., 4 Desember 2020

PTPS .......................................

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NB : Jangan Lupa Dokumentasi