BADAN PEMERIKSA KEUANGAN

FORM PENGISIAN KONFIRMASI PENYETORAN PENDAPATAN

TAHUN ANGGARAN 2020

Petunjuk Pengisian:
1. Mohon untuk tidak merubah format excel penulisan pada form ini (tulis tanggal sesuai dengan format excel yg ada) dan tidak
menambahkan kolom kekanan dan/atau kiri.
2. Mohon isikan kolom "No. STS" sesuai dengan nomor seluruh STS selama TA 2020.
3. Mohon isikan kolom "Nilai STS" sesuai dengan nilai setoran masing-masing STS selama TA 2020.
4. Mohon isikan kolom "Tanggal STS" sesuai dengan tanggal masing-masing STS selama TA 2020.
5. Mohon isikan kolom "Penyetoran Pendapatan yang Diterima dari Tanggal" sesuai dengan tanggal awal penerimaan Pendapatan
atas STS terkait berdasarkan kondisi sesungguhnya dan/atau catatan penerimaan PKM.
6. Mohon isikan kolom "Penyetoran Pendapatan yang Diterima Hingga Tanggal" sesuai dengan tanggal terakhir penerimaan
Pendapatan atas STS terkait berdasarkan kondisi sesungguhnya dan/atau catatan penerimaan PKM.
7. Mohon pastikan jika seluruh STS telah terisi pada Form Pengisian Konfirmasi Penyetoran Pendapatan dengan membandingkan
antara nilai total pada tabel dengan nilai realisasi pendapatan PKM selama TA 2020.

Daftar Jangka Waktu Penyetoran Pendapatan UPT Puskesmas Muara Pahu 2020
Penyetoran Pendapatan yang Diterima
No No. STS Nilai STS Tanggal STS
Dari Tanggal Hingga Tanggal
1 0001/STS/PKMMP/I/2020 Rp 268,000.00 1/9/2020 02/01/2020 1/9/2020
2 0002/STS/PKMMP/I/2020 Rp 20,000.00 1/10/2020 1/10/2020 1/10/2020
3 0003/STS/PKMMP/I/2020 Rp 94,000.00 1/13/2020 1/11/2020 1/13/2020
4 0004/STS/PKMMP/I/2020 Rp 64,000.00 1/15/2020 1/14/2020 1/15/2020
5 0005/STS/PKMMP/I/2020 Rp 150,000.00 1/16/2020 1/16/2020 1/16/2020
6 0006/STS/PKMMP/I/2020 Rp 56,000.00 1/17/2020 1/17/2020 1/17/2020
7 0007/STS/PKMMP/I/2020 Rp 201,000.00 1/20/2020 1/18/2020 1/20/2020
8 0008/STS/PKMMP/I/2020 Rp 124,000.00 1/21/2020 1/21/2020 1/21/2020
9 0009/STS/PKMMP/I/2020 Rp 62,000.00 1/22/2020 1/22/2020 1/22/2020
10 0010/STS/PKMMP/I/2020 Rp 127,000.00 1/23/2020 1/23/2020 1/23/2020
11 0011/STS/PKMMP/I/2020 Rp 311,000.00 1/27/2020 1/24/2020 1/27/2020
12 0012/STS/PKMMP/I/2020 Rp 146,000.00 1/28/2020 1/28/2020 1/28/2020
13 0013/STS/PKMMP/I/2020 Rp 30,000.00 1/29/2020 1/29/2020 1/29/2020
14 0014/STS/PKMMP/II/2020 Rp 703,000.00 2/10/2020 1/30/2020 2/10/2020
15 0015/STS/PKMMP/II/2020 Rp 161,000.00 2/11/2020 2/11/2020 2/11/2020
16 0016/STS/PKMMP/II/2020 Rp 158,000.00 2/12/2020 2/12/2020 2/12/2020
17 0017/STS/PKMMP/II/2020 Rp 48,000.00 2/13/2020 2/13/2020 2/13/2020
18 0018/STS/PKMMP/II/2020 Rp 217,000.00 2/14/2020 2/14/2020 2/14/2020
19 0019/STS/PKMMP/II/2020 Rp 426,000.00 2/17/2020 2/15/2020 2/17/2020
20 0020/STS/PKMMP/II/2020 Rp 82,000.00 2/18/2020 2/18/2020 2/18/2020
21 0021/STS/PKMMP/II/2020 Rp 120,000.00 2/19/2020 2/19/2020 2/19/2020
22 0022/STS/PKMMP/II/2020 Rp 31,000.00 2/20/2020 2/20/2020 2/20/2020
23 0023/STS/PKMMP/II/2020 Rp 220,000.00 2/21/2020 2/21/2020 2/21/2020
24 0024/STS/PKMMP/II/2020 Rp 91,000.00 2/24/2020 2/22/2020 2/24/2020
25 0025/STS/PKMMP/II/2020 Rp 69,000.00 2/25/2020 2/25/2020 2/25/2020
26 0026/STS/PKMMP/II/2020 Rp 280,000.00 2/26/2020 2/26/2020 2/26/2020
27 0027/STS/PKMMP/III/2020 Rp 271,000.00 3/5/2020 2/27/2020 3/5/2020
28 0028/STS/PKMMP/III/2020 Rp 147,000.00 3/9/2020 3/6/2020 3/9/2020
29 0029/STS/PKMMP/III/2020 Rp 148,000.00 3/17/2020 3/10/2020 3/17/2020
30 0030/STS/PKMMP/III/2020 Rp 119,000.00 3/18/2020 3/18/2020 3/18/2020
31 0031/STS/PKMMP/III/2020 Rp 20,000.00 3/19/2020 3/19/2020 3/19/2020
32 0032/STS/PKMMP/III/2020 Rp 33,000.00 3/20/2020 3/20/2020 3/20/2020
33 0033/STS/PKMMP/III/2020 Rp 157,000.00 3/26/2020 3/21/2020 3/26/2020
34 0034/STS/PKMMP/III/2020 Rp 466,000.00 3/30/2020 3/27/2020 3/30/2020
35 0035/STS/PKMMP/IV/2020 Rp 216,000.00 4/1/2020 3/31/2020 4/1/2020
36 0036/STS/PKMMP/IV/2020 Rp 18,000.00 4/3/2020 4/2/2020 4/3/2020
37 0037/STS/PKMMP/IV/2020 Rp 58,000.00 4/6/2020 4/4/2020 4/6/2020
38 0038/STS/PKMMP/IV/2020 Rp 42,000.00 4/7/2020 4/7/2020 4/7/2020
39 0039/STS/PKMMP/IV/2020 Rp 48,000.00 4/9/2020 4/8/2020 4/9/2020
40 0040/STS/PKMMP/IV/2020 Rp 57,000.00 4/13/2020 4/11/2020 4/13/2020
41 0041/STS/PKMMP/IV/2020 Rp 44,000.00 4/14/2020 4/14/2020 4/14/2020
42 0042/STS/PKMMP/IV/2020 Rp 48,000.00 4/16/2020 4/15/2020 4/16/2020
43 0043/STS/PKMMP/IV/2020 Rp 42,000.00 4/21/2020 4/17/2020 4/21/2020
44 0044/STS/PKMMP/IV/2020 Rp 442,500.00 4/23/2020 4/22/2020 4/23/2020
45 0045/STS/PKMMP/IV/2020 Rp 39,000.00 4/27/2020 4/24/2020 4/27/2020
46 0046/STS/PKMMP/V/2020 Rp 90,000.00 5/4/2020 4/28/2020 5/4/2020
47 0047/STS/PKMMP/V/2020 Rp 46,000.00 5/8/2020 5/5/2020 5/8/2020
48 0048/STS/PKMMP/V/2020 Rp 45,000.00 5/12/2020 5/9/2020 5/12/2020
49 0049/STS/PKMMP/V/2020 Rp 44,000.00 5/15/2020 5/13/2020 5/15/2020
50 0050/STS/PKMMP/V/2020 Rp 48,000.00 5/19/2020 5/16/2020 5/19/2020
51 0051/STS/PKMMP/V/2020 Rp 61,000.00 5/26/2020 5/20/2020 5/26/2020
52 0052/STS/PKMMP/V/2020 Rp 292,000.00 5/27/2020 5/27/2020 5/27/2020
53 0053/STS/PKMMP/VI/2020 Rp 130,000.00 6/2/2020 5/28/2020 6/2/2020
54 0054/STS/PKMMP/VI/2020 Rp 73,000.00 6/4/2020 6/3/2020 6/4/2020
55 0055/STS/PKMMP/VI/2020 Rp 62,000.00 6/5/2020 6/5/2020 6/5/2020
56 0056/STS/PKMMP/VI/2020 Rp 73,000.00 6/8/2020 6/6/2020 6/8/2020
57 0057/STS/PKMMP/VI/2020 Rp 36,000.00 6/12/2020 6/9/2020 6/12/2020
58 0058/STS/PKMMP/VI/2020 Rp 102,000.00 6/15/2020 6/13/2020 6/15/2020
59 0059/STS/PKMMP/VI/2020 Rp 30,000.00 6/16/2020 6/16/2020 6/16/2020
60 0060/STS/PKMMP/VI/2020 Rp 53,000.00 6/17/2020 6/17/2020 6/17/2020
61 0061/STS/PKMMP/VI/2020 Rp 40,000.00 6/18/2020 6/18/2020 6/18/2020
62 0062/STS/PKMMP/VI/2020 Rp 102,000.00 6/23/2020 6/19/2020 6/23/2020
63 0063/STS/PKMMP/VI/2020 Rp 78,000.00 6/24/2020 6/24/2020 6/24/2020
 64 0064/STS/PKMMP/VI/2020 Rp 113,000.00 6/25/2020 6/25/2020 6/25/2020
65 0065/STS/PKMMP/VI/2020 Rp 460,000.00 6/29/2020 6/26/2020 6/29/2020
66 0066/STS/PKMMP/VII/2020 Rp 220,000.00 7/1/2020 6/30/2020 7/1/2020
67 0067/STS/PKMMP/VII/2020 Rp 75,000.00 7/2/2020 7/2/2020 7/2/2020
68 0068/STS/PKMMP/VII/2020 Rp 107,000.00 7/3/2020 7/3/2020 7/3/2020
69 0069/STS/PKMMP/VII/2020 Rp 55,000.00 7/6/2020 7/4/2020 7/6/2020
70 0070/STS/PKMMP/VII/2020 Rp 197,000.00 7/7/2020 7/7/2020 7/7/2020
71 0071/STS/PKMMP/VII/2020 Rp 72,000.00 7/8/2020 7/8/2020 7/8/2020
72 0072/STS/PKMMP/VII/2020 Rp 231,000.00 7/10/2020 7/9/2020 7/10/2020
73 0073/STS/PKMMP/VII/2020 Rp 93,000.00 7/14/2020 7/11/2020 7/14/2020
74 0074/STS/PKMMP/VII/2020 Rp 151,000.00 7/15/2020 7/15/2020 7/15/2020
75 0075/STS/PKMMP/VII/2020 Rp 65,000.00 7/17/2020 7/16/2020 7/17/2020
76 0076/STS/PKMMP/VII/2020 Rp 183,000.00 7/21/2020 7/18/2020 7/21/2020
77 0077/STS/PKMMP/VII/2020 Rp 137,000.00 7/22/2020 7/22/2020 7/22/2020
78 0078/STS/PKMMP/VII/2020 Rp 181,000.00 7/24/2020 7/23/2020 7/24/2020
79 0079/STS/PKMMP/VII/2020 Rp 300,000.00 7/27/2020 7/25/2020 7/27/2020
80 0080/STS/PKMMP/VIII/2020 Rp 147,000.00 8/4/2020 7/28/2020 8/4/2020
81 0081/STS/PKMMP/VIII/2020 Rp 48,000.00 8/7/2020 8/5/2020 8/7/2020
82 0082/STS/PKMMP/VIII/2020 Rp 69,000.00 8/10/2020 8/8/2020 8/10/2020
83 0083/STS/PKMMP/VIII/2020 Rp 49,000.00 8/12/2020 8/11/2020 8/12/2020
84 0084/STS/PKMMP/VIII/2020 Rp 109,000.00 8/18/2020 8/13/2020 8/18/2020
85 0085/STS/PKMMP/VIII/2020 Rp 78,000.00 8/19/2020 8/19/2020 8/19/2020
86 0086/STS/PKMMP/VIII/2020 Rp 80,000.00 8/24/2020 8/21/2020 8/24/2020
87 0087/STS/PKMMP/VIII/2020 Rp 173,000.00 8/26/2020 8/25/2020 8/26/2020
88 0088/STS/PKMMP/VIII/2020 Rp 119,000.00 8/27/2020 8/27/2020 8/27/2020
89 0089/STS/PKMMP/VIII/2020 Rp 186,000.00 8/31/2020 8/28/2020 8/31/2020
90 0090/STS/PKMMP/IX/2020 Rp 116,000.00 9/1/2020 9/1/2020 9/1/2020
91 0091/STS/PKMMP/IX/2020 Rp 97,000.00 9/2/2020 9/2/2020 9/2/2020
92 0092/STS/PKMMP/IX/2020 Rp 132,000.00 9/3/2020 9/3/2020 9/3/2020
93 0093/STS/PKMMP/IX/2020 Rp 191,000.00 9/7/2020 9/4/2020 9/7/2020
94 0094/STS/PKMMP/IX/2020 Rp 35,000.00 9/10/2020 9/8/2020 9/10/2020
95 0095/STS/PKMMP/IX/2020 Rp 91,000.00 9/14/2020 9/11/2020 9/14/2020
96 0096/STS/PKMMP/IX/2020 Rp 78,000.00 9/17/2020 9/15/2020 9/17/2020
97 0097/STS/PKMMP/IX/2020 Rp 78,000.00 9/21/2020 9/18/2020 9/21/2020
98 0098/STS/PKMMP/IX/2020 Rp 242,000.00 9/22/2020 9/22/2020 9/22/2020
99 0099/STS/PKMMP/IX/2020 Rp 166,000.00 9/23/2020 9/23/2020 9/23/2020
100 0100/STS/PKMMP/IX/2020 Rp 156,000.00 9/24/2020 9/24/2020 9/24/2020
101 0101/STS/PKMMP/IX/2020 Rp 264,000.00 9/25/2020 9/25/2020 9/25/2020
102 0102/STS/PKMMP/IX/2020 Rp 224,000.00 9/28/2020 9/26/2020 9/28/2020
103 0103/STS/PKMMP/X/2020 Rp 548,000.00 10/1/2020 9/29/2020 10/1/2020
104 0104/STS/PKMMP/X/2020 Rp 100,000.00 10/2/2020 10/2/2020 10/2/2020
105 0105/STS/PKMMP/X/2020 Rp 309,000.00 10/5/2020 10/3/2020 10/5/2020
106 0106/STS/PKMMP/X/2020 Rp 360,000.00 10/6/2020 10/6/2020 10/6/2020
107 0107/STS/PKMMP/X/2020 Rp 140,000.00 10/7/2020 10/7/2020 10/7/2020
108 0108/STS/PKMMP/X/2020 Rp 251,000.00 10/8/2020 10/8/2020 10/8/2020
109 0109/STS/PKMMP/X/2020 Rp 180,000.00 10/9/2020 10/9/2020 10/9/2020
110 0110/STS/PKMMP/X/2020 Rp 306,000.00 10/12/2020 10/10/2020 10/12/2020
111 0111/STS/PKMMP/X/2020 Rp 266,000.00 10/13/2020 10/13/2020 10/13/2020
112 0112/STS/PKMMP/X/2020 Rp 178,000.00 10/14/2020 10/14/2020 10/14/2020
113 0113/STS/PKMMP/X/2020 Rp 110,000.00 10/15/2020 10/15/2020 10/15/2020
114 0114/STS/PKMMP/X/2020 Rp 76,000.00 10/16/2020 10/16/2020 10/16/2020
115 0115/STS/PKMMP/X/2020 Rp 78,000.00 10/19/2020 10/17/2020 10/19/2020
116 0116/STS/PKMMP/X/2020 Rp 129,000.00 10/20/2020 10/20/2020 10/20/2020
117 0117/STS/PKMMP/X/2020 Rp 280,000.00 10/21/2020 10/21/2020 10/21/2020
118 0118/STS/PKMMP/X/2020 Rp 207,000.00 10/22/2020 10/22/2020 10/22/2020
119 0119/STS/PKMMP/X/2020 Rp 600,000.00 10/23/2020 10/23/2020 10/23/2020
120 0120/STS/PKMMP/X/2020 Rp 176,000.00 10/26/2020 10/24/2020 10/26/2020
121 0121/STS/PKMMP/XI/2020 Rp 143,000.00 11/2/2020 10/27/2020 11/2/2020
122 0122/STS/PKMMP/XI/2020 Rp 124,000.00 11/6/2020 11/3/2020 11/6/2020
123 0123/STS/PKMMP/XI/2020 Rp 98,000.00 11/9/2020 11/7/2020 11/9/2020
124 0124/STS/PKMMP/XI/2020 Rp 135,000.00 11/11/2020 11/10/2020 11/11/2020
125 0125/STS/PKMMP/XI/2020 Rp 86,000.00 11/13/2020 11/12/2020 11/13/2020
126 0126/STS/PKMMP/XI/2020 Rp 125,000.00 11/17/2020 11/14/2020 11/17/2020
127 0127/STS/PKMMP/XI/2020 Rp 86,000.00 11/19/2020 11/18/2020 11/19/2020
128 0128/STS/PKMMP/XI/2020 Rp 79,000.00 11/23/2020 11/20/2020 11/23/2020
129 0129/STS/PKMMP/XI/2020 Rp 230,000.00 11/24/2020 11/24/2020 11/24/2020
130 0130/STS/PKMMP/XI/2020 Rp 300,000.00 11/25/2020 11/25/2020 11/25/2020
131 0131/STS/PKMMP/XI/2020 Rp 228,000.00 11/26/2020 11/26/2020 11/26/2020
132 0132/STS/PKMMP/XII/2020 Rp 60,000.00 12/1/2020 11/27/2020 12/1/2020
133 0133/STS/PKMMP/XII/2020 Rp 98,000.00 12/4/2020 12/2/2020 12/4/2020
134 0134/STS/PKMMP/XII/2020 Rp 103,000.00 12/7/2020 12/5/2020 12/7/2020
135 0135/STS/PKMMP/XII/2020 Rp 108,000.00 12/10/2020 12/8/2020 12/10/2020
136 0136/STS/PKMMP/XII/2020 Rp 121,000.00 12/14/2020 12/11/2020 12/14/2020
137 0137/STS/PKMMP/XII/2020 Rp 124,000.00 12/16/2020 12/15/2020 12/16/2020
138 0138/STS/PKMMP/XII/2020 Rp 89,000.00 12/18/2020 12/17/2020 12/18/2020
139 0139/STS/PKMMP/XII/2020 Rp 64,000.00 12/21/2020 12/19/2020 12/21/2020
140 0140/STS/PKMMP/XII/2020 Rp 268,000.00 12/23/2020 12/22/2020 12/23/2020
141 0141/STS/PKMMP/XII/2020 Rp 144,500.00 12/28/2020 12/26/2020 12/28/2020
TOTAL Rp 20,755,000.00

Muara Pahu, 16 Februari 2021

Plt.Kepala UPT Puskesmas Muara Pahu

NOOR ADHA
NIP.19690219 198811 1 001