Model

FORMULIR MODEL A
LAPORAN HASIL PENGAWASAN

I DATA PENGAWASAN
a. Nama/Tim Pengawas : .............................................................................................
b. Jabatan :..............................................................................................
c. Alamat/Domisili : .............................................................................................

II KEGIATAN PENGAWASAN
a) Tahapan Yang Diawasi : .............................................................................................
b) PEMUNGUTAN SUARA
c) Bentuk Pengawasan :.............................................................................................
d) Pihak yang diawasi : .............................................................................................
e) Hari : .............................................................................................
f) Tanggal : .............................................................................................
Bulan : .............................................................................................
Tahun : .........................................................................
Pukul : .............................................................................................
Tempat/Lokasi : .............................................................................................

III URAIAN HASIL PENGAWASAN

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DOKUMENTASI TERLAMPIR

IV DUGAAN PELANGGARAN : a. Ada b. Tidak Ada

V INFORMASI DUGAAN PELANGGARAN:

a. Tempat Kejadian :

b. Waktu Kejadian :

c. Nama Pelaku :

d. Status Pelaku :

VI URAIAN DUGAAN PELANGGARAN :

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VII SAKSI-SAKSI
a. Saksi I : .........................................................................
b. Saksi II :.............................................................................
c. Saksi III :...........................................................................

VIII BUKTI PENDUKUNG

a. ……………………………………………………………………………….
b. ……………………………………………………………………………….
c. ………………………………………………………………………………

Sidomulyo, ...........Desember 2020

Pengawas TPS

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