FORMULIR MODEL A

LAPORAN HASIL PENGAWASAN

PANWASLU KECAMATAN KERTAJATI

I. Data Pengawas

a. Nama / Tim Pengawasan :___________________________________________________________

b. Jabatan : ___________________________________________________________

c. Alamat Domisili : ___________________________________________________________

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II. Kegiatan Pengawasan

a. Tahapan yang diawasi : ___________________________________________________________

b. Bentuk Pengawasn : a. Langsung b. Tidak Langsung (Analisis Investigasi)

c. Pihak yang diawasi : ___________________________________________________________

d. Waktu : a. Hari : ________________________________________

b. Tanggal : ________________________________________

c. Bulan : ________________________________________

d. Tahun : 20____

e. Jam : __________ sd ________ WIB

f. Tempat/Lokasi : ________________________________________

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III. Uraian Pengawasan :

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 FORMULIR MODEL A

IV. Dugaan Pelanggaran : a. Ada b. Tidak

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 : _____________________________________________________

VIII. Bukti Pendukung

a. Bukti I : _____________________________________________________

b. Bukti II : _____________________________________________________

_____________, _____________, 20___

Pengawas

( ______________________________ )