UPK (UNIT PENGELOLA KEGIATAN)

MANDIRI SEJAHTERA
KECAMATAN ARJOSARI KABUPATEN PACITAN

BERKAS
VERIFIKASI PERGULIRAN SPP

KELOMPOK :
DESA :

Sekretariat :
JL. Raya Arjosari-Ponorogo
RT/RW 01/07 Dusun Semo Desa Arjosari
Kecamatan Arjosari Kabupaten Pacitan
 Tahun 2021BERITA ACARA
KUNJUNGAN LAPANGAN
TIM VERIFIKASI PERGULIRAN

Dalam rangka pelaksanaan Kerjasama antar desa di Kecamatan Arjosari Kabupaten

Pacitan Provinsi Jawa Timur, maka pada :
Hari dan Tanggal :
Jam :
Tempat :
Telah diselenggarakan kunjungan lapangan (Verifikasi SPP Perguliran) yang dihadiri oleh
pengurus dan anggota kelompok, serta unsur lain yang terikat dengan pelaksanaan SPP
perguliran sebagaimana tercantum dalam daftar hadir.

Materi atau topik yang dibahas dalam forum ini serta yang bertindak selaku unsur
pimpiman rapat dan narasumber adalah ;
A. Materi atau topik ;
1. Pembukaan
2. Sambutan Ketua Tim Verifikasi
3. Kunjungan Lapangan
4. Umpan balik hasil kunjungan lapangan
5. Penutup

B. Unsur pimpinan rapat dan narasumber ;

1. Pimpinan rapat :……………………..dari……………………..
2. Sekretaris/Notulensi :……………………..dari……………………..
3. Narasumber : 1). …………………dari Tim Verifikasi
2). ………………...dari Tim Verifikasi
3). ………………...dari Tim Verifikasi

Demikian berita acara ini dibuat dan disahkan dengan penuh tanggungjawab agar
dipergunakan dengan sebagaimana mestinya.
 …………….., …………………………… 2021
Ketua Tim Verifikasi Ketua

(……………………) (……………………)

Mengetahui,
Kepala Desa …………………

(..……………………)

Mengetahui dan menyetujui

Dari peserta musyawarah,

Nama Alamat Tanda Tangan

1. ……………………. ………………………………………. …………………….

2. ……………………. ………………………………………. …………………….
3. ……………………. ………………………………………. …………………….
4. ……………………. ………………………………………. …………………….
5. ……………………. ………………………………………. …………………….
6. ……………………. ………………………………………. …………………….
7. ……………………. ………………………………………. …………………….
8. ……………………. ………………………………………. …………………….
9. ……………………. ………………………………………. …………………….
10. ……………………. ………………………………………. …………………….
 NOTULENSI
KUNJUNGAN LAPANGAN TIM VERIFIKASI PERGULIRAN
TAHUN 2021
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
............................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................

…………., ……....……………2021

Notulis/Sekretaris

(…………………….)
 DAFTAR HADIR
KUNJUNGAN LAPANGAN TIM VERIFIKASI PERGULIRAN
TAHUN 2021

No. Nama Jabatan Tanda Tangan

1. 1.

2. 2.

3. 3.

4. 4.

5. 5.

6. 6.

7. 7.

8. 8.

9. 9.

10. 10.

…………., ……....……………2021

Pimpinan Rapat

(………………………)