FORM.

LAPORAN HASIL PENGAWASAN PEMILU

NOMOR : 005 /LHP/PM.01.02/02/2023

I. Data Pengawasan
a. Tahapan yang diawasi : Verifikasi Faktual Calon Perseorangan
Anggota DPD
b. Nama Pelaksana Tugas Pengawasan : Mustofa
c. Jabatan : Panwaslu Kelurahan/Desa
d. Nomor Surat Perintah Tugas : 003/PM.00.02/K.JL-01.18/02/2023
e. Alamat : Desa Galis
II. Kegiatan Pengawasan
a. Bentuk : Pengawasan Langsung
b. Tujuan : Melakukan Pengawasan Verfak Dukungan
Perseorangan Calon Anggota DPD
c. Sasaran : PPS dan Pantarlih
d. Waktu dan tempat : Kerumah warga
III. Uraian Singkat Hasil Pengawasan :

Pada hari Minggu tanggal 19 Februari 2023 jam 09.00 WIB. Panwaslu Kelurahan/Desa
melakukan pengawasan verfak dukungan perseorangan calon anggota DPD. Pada saat
verfak calon DPD, di dampingi langsung oleh panwaslu kecamatan Galis.

Saat dilakukan verfak oleh PPS, yang bersangkutan atas nama Mat Suri dan Sri Utami
menyatakan mendukung terhadap salah satu calon atas nama AA. Ahmad Nawardi.

IV. Informasi Dugaan Pelanggaran:

1. Peristiwa
a. Peristiwa : ...................................................................................
b. Tempat Kejadian : ...................................................................................
c. Waktu Kejadian : ...................................................................................
d. Pelaku : ...................................................................................
e. Alamat : ...................................................................................
2. Saksi-Saksi
a. Nama : ...................................................................................
Alamat : ...................................................................................
b. Nama : ...................................................................................
Alamat : ...................................................................................
 3. Alat Bukti :
a. ........................................................................................................................................
b. ........................................................................................................................................
c. ........................................................................................................................................
4. Barang Bukti :
a. ........................................................................................................................................
b. ........................................................................................................................................
c. ........................................................................................................................................

5. Uraian Singkat Dugaan Pelanggaran:

........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
6. Fakta dan Keterangan:
........................................................................................................................................
........................................................................................................................................
7. Analisa
........................................................................................................................................
........................................................................................................................................
V. Informasi Potensi Sengketa
1. Peristiwa :
a. Peserta Pemilu : ...................................................................................
b. Tempat Kejadian : ...................................................................................
c. Waktu Kejadian : ...................................................................................
2. Objek Sengketa :
a. Bentuk Objek Sengketa : ...................................................................................
b. Identitas Objek Sengketa : ...................................................................................
c. Hari/Tanggal dikeluarkan : ...................................................................................
d. Kerugian langsung : ...................................................................................
3. Uraian Singkat Potensi Sengketa:
..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................

Bangkalan, 18 Februari 2023

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