FORMULIR MODEL B.

FORMULIR LAPORAN
Nomor : ..............................................................

1. Identitas Pelapor :
a. Nama : ...............................................................
b. Tempat/ Tgl. Lahir : ...............................................................
c. enis Kelamin : ...............................................................
d. Pekerjaan : ...............................................................
e. Kewarganegaraan : ...............................................................
f. Alamat : ...............................................................
g. No. Telp/HP : ...............................................................
h. E-Mail*** : ...............................................................
2. Identitas Terlapor :
a. Nama : ...............................................................
b. Alamat** : ...............................................................
c. No. Telp/HP*** : ...............................................................
3. Peristiwa yang dilaporkan :
a. Peristiwa : ...............................................................
b. Tempat Kejadian : ...............................................................
c. Hari dan Tanggal Kejadian : ...............................................................
d. Hari dan Tanggal diketahui : ...............................................................
4. Saksi-saksi ***
1) Nama : ...............................................................
Alamat : ...............................................................
No. Telp/HP : ...............................................................
2) Nama : ...............................................................
Alamat : ...............................................................
No. Telp/HP : ...............................................................
5. Bukti – Bukti :
a. ....................................................................................................................
b. ....................................................................................................................
c. ....................................................................................................................
d. ....................................................................................................................
e. ....................................................................................................................
f. ....................................................................................................................

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6. Uraian Kejadian :
(diuraikan secara kronologis peristiwa apa yang dianggap sebagai dugaan pelanggaran pemilu,
di mana, kapan, dan bagaimana peristiwa tersebut terjadi)
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Dilaporkan di : ................................................
Hari dan Tanggal : ................................................
Pukul : ................................................

Saya menyatakan bahwa isi laporan ini adalah yang sebenar-benarnya dan saya bersedia
mempertanggungjawabkannya di hadapan hukum.

Penerima Laporan Pelapor

....................................... ..........................................

Keterangan :
* diberi nomor penyampaian laporan
** jika alamat tempat tanggal Terlapor tidak lengkap/tidak diketahui, cukup
disebutkan dusun/desa/kelurahan
*** tidak wajib diisi