FORMULIR TANGGAPAN/MASUKAN MASYARAKAT

TERHADAP CALON ANGGOTA PANWASLU DESA

Sapeken, ……,…….………, 2023

Kepada Yth.
Nomor : ....................... Ketua Pokja Pembentukan Panwaslu
Sifat : ....................... Desa Kecamatan Sapeken
Lampiran : ....................... di_
Perihal :........................ S AP EK EN

1. Pelapor
a. Nama : .....................................................................................
b. Nomor Identitas (KTP) : .....................................................................................
c. Tempat/Tanggal Lahir : .....................................................................................
d. Jenis kelamin : .....................................................................................
e. Pekerjaan : .....................................................................................
f. Kewarganegaraan : .....................................................................................
g. Alamat : .....................................................................................
h. No. Telp/WA : .....................................................................................
i. Email : .....................................................................................
2. Uraian tanggapan/masukan:
. .....................................................................................................................................
. .....................................................................................................................................
. .....................................................................................................................................
. .....................................................................................................................................
3. Bukti-bukti:
a. . ................................................................................................................................
b. . ................................................................................................................................
c. . ................................................................................................................................

Saya menyatakan bahwa isi laporan ini adalah yang sebenar-benarnya dan saya
bersedia mempertanggungjawabkan dihadapan hukum.

Pelapor

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