Kepada :
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.........NAMA.........
Kepada :
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NAMA
Kepada :
Yth. .........................................
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di -
TEMPAT
SURAT EDARAN
NOMOR : ...............................
TENTANG
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NAMA
SURAT KETERANGAN
NOMOR : ..........................
.........NAMA.........
4. SURAT IZIN
a. Ditandatangani Kepala Desa
SURAT IZIN
NOMOR : ..........................
TENTANG
.......................................
.......................................
Dasar : a. ...................................................................................................
b. ...................................................................................................
MEMBERI IZIN :
Kepada :
Nama : .......................................................................................................
Jabatan : ........................................................................................................
Alamat : ........................................................................................................
Untuk : ........................................................................................................
.........NAMA.........
b. Ditandatangani BPD
TENTANG
.......................................
.......................................
Dasar : a. ..................................................................................................
b. ..................................................................................................
MEMBERI IZIN :
Kepada :
Nama : .........................................................................................................
Jabatan : .........................................................................................................
Alamat : .........................................................................................................
Untuk : .........................................................................................................
NAMA
5. SURAT PERJANJIAN
SURAT PERJANJIAN
NOMOR : ………./………./………/……..
TENTANG
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Pasal .....
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................................................................................................. (isi perjanjian)
Pasal .....
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.................................................................................................. (isi perjanjian)
Penutup
Surat perjanjian ini ditandatangani oleh kedua belah pihak, pada hari dan
tanggal tersebut diatas.
PIHAK KE II PIHAK KE I
KEPALA DESA .......,
FORMAT MAP
DAERAH
6. SURAT PERINTAH
SURAT PERINTAH
NOMOR ………………………….
MEMERINTAHKAN :
Kepada :
a. Nama : ...................................................
b. Jabatan : ....................................................
Untuk :
........................................................................................................
.................................................................................................................. ...
........................................................................................................
..................................................................................................................
Ditetapkan di …………………..
pada tanggal …………………..
NAMA
7. SURAT PERINTAH PERJALANAN DINAS
a. Ditandatangani Kepala Desa
NOMOR …………………
Dasar : ....................................................................................
MEMERINTAHKAN :
2. Nama : .......................................................
Pangkat/gol: .......................................................
NIP/NIAP : .......................................................
Jabatan : .......................................................
Untuk : 1. .......................................................................
2. .......................................................................
3. .......................................................................
Ditetapkan di …………………..
pada tanggal ……………………
NAMA
b. Ditandatangani BPD
NOMOR …………………
Dasar : ....................................................................................
MEMERINTAHKAN :
2. Nama : .......................................................
Pangkat/gol: .......................................................
NIP : .......................................................
Jabatan : .......................................................
Untuk : 1. .......................................................................
2. .......................................................................
3. .......................................................................
Ditetapkan di …………………..
pada tanggal ……………………
NAMA
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN MESTONG
PEMERINTAH DESA NAGASARI
Jalan Lintas Jambi Palembang KM. 24 RT. 02 Kode Pos 36364
Email: nagasariwonderfull@gmail.com
Lembar ke : II
Kode No : 090
Nomor : /Skrt/NS/2023
3. a. Jabatan
6. a. Tempat berangkat
b. Tempat Tujuan
8. Pengikut
9. Pembebanan Anggaran
a. Instansi
b. Mata Anggaran
Dikeluarkan di ..............
pada tanggal ..............
NAMA
b. Ditandatangani BPD
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN ...........
BADAN PERMUSYAWARATAN DESA ...........
Jl. ….…No…….Telp………Fax…… Kode Pos……. Website............
Lembar ke : ..........................................
Kode No : ..........................................
Nomor : ..........................................
3. a. Jabatan
6. a. Tempat berangkat
b. Tempat Tujuan
8. Pengikut
9. Pembebanan Anggaran
a. Instansi
b. Mata Anggaran
Dikeluarkan di ...............
pada tanggal ...............
NAMA
c. Belakang SPPD
SPPD No. : .........................
Berangkat dari
(tempat kedudukan) : .........................
Pada tanggal : .........................
Ke : ...........................
.....................
V. Tiba kembali di :
Pada tanggal : ..................................................
Telah diperiksa, dengan keterangan bahwa
perjalanan tersebut diatas benar dilakukan atas
perintahnya dan semata-mata untuk
kepentingan jabatan dalam waktu yang
sesingkat-singkatnya.
SEKRETARIS DESA,
NAMA
___________________________________________________________________
VI. CATATAN LAIN-LAIN
___________________________________________________________________
VII. PERHATIAN
Pejabat yang berwenang menerbitkan SPPD, pegawai yang melakukan
perjalanan dinas, para pejabat yang mengesahkan tanggal berangkat/tiba
serta Bendaharawan bertanggung jawab berdasarkan peraturan-
peraturan Keuangan Negara apabila Negara mendapat rugi akibat
kesalahan, kealpaannya.
9. SURAT KUASA
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN ...........
PEMERINTAH DESA .........
Jl. ….…No…….Telp………Fax…… Kode Pos……. Website............
SURAT KUASA
Nomor . . . . . . . . . . . . . .
MEMBERI KUASA
Kepada :
a. Nama : ……………………………………
b. Jabatan : ……………………………………
c. NIP. : ……………………………………
Untuk :
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.........................................................................................................................
............................
NAMA NAMA
Kepada :
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......................................................................................................
.........
Hari/Tanggal : ................................................
Tempat : ................................................
Acara : ................................................
.............................................................................................
......................................................................................................
....................
NAMA
Catatan :
1. ....................................................
2. .................................................
b. Ditandatangani BPD
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN ...........
BADAN PERMUSYAWARATAN DESA ...........
Jl. ….…No…….Telp………Fax…… Kode Pos……. Website............
Kepada :
Nomor : 005/......./....... Yth. ............................................
Sifat : ....................... ............................................
Lampiran : .......................
Hal : Undangan di -
......................
..........................................................................................
.......................................................................................................
..........
Hari : ................................................
Tanggal : ................................................
Waktu : Pukul 08.30 Wib s.d. selesai.
Tempat : ................................................
Acara : ................................................
..........................................................................................
.......................................................................................................
..........
NAMA
Catatan :
1. .............................................
2. ..............................................
Nama : ...................................................
NIP : ....................................................
Pangkat/Golongan : ....................................................
Jabatan : ....................................................
Nama : ...................................................
NIP : ....................................................
Pangkat/Golongan : ....................................................
Jabatan : ....................................................
NAMA
Kepada :
Nomor : ....................... Yth. ............................................
Sifat : ....................... ............................................
Lampiran : .......................
Hal : Panggilan di -
......................
Hari : ................................................
Tanggal : ................................................
Pukul : ................................................
Tempat : ................................................
Menghadap
kepada : ................................................
Alamat : ................................................
Untuk : ................................................
NAMA
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN MESTONG
PEMERINTAH DESA NAGASARI
Jalan Lintas Jambi Palembang KM. 24 RT. 02 Kode Pos 36364
Email: nagasariwonderfull@gmail.com
NOTA DINAS
Kepada : .....................................................................
Dari : .....................................................................
Tanggal : .....................................................................
Nomor : .....................................................................
Sifat : .....................................................................
Lampiran : .....................................................................
Hal : .........................................................................
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SEKRETARIS DESA/KASI/KAUR,
NAMA
NIP/NIAP.
LEMBAR DISPOSISI
Perihal :
Catatan :
LEMBAR DISPOSISI
Perihal :
Catatan :
15. PENGUMUMAN
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN ...........
PEMERINTAH DESA .........
Jl. ….…No…….Telp………Fax…… Kode Pos……. Website............
PENGUMUMAN
NOMOR : ……………
TENTANG
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Ditetapkan di …………………….
pada tanggal………………………
NAMA
16. LAPORAN
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN ...........
PEMERINTAH DESA .........
Jl. ….…No…….Telp………Fax…… Kode Pos……. Website............
LAPORAN
TENTANG
.............................................................................
.............................................................................
I. Pendahuluan.
A. Umum/latar belakang
B. Landasan Hukum
C. Maksud dan Tujuan
V. Penutup.
Dibuat di ..................
pada tanggal ..................
NAMA
17. REKOMENDASI
PEMERINTAH KABUPATEN MUARO JAMBI
KECAMATAN ...........
PEMERINTAH DESA .........
Jl. ….…No…….Telp………Fax…… Kode Pos……. Website............
REKOMENDASI ............
NOMOR ............
................................................................................................................
.........................................................................................................................
.........................................................................................................................
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a. …………………………………………………………………………………………………
……........................………………………..........................................................
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b. ………………………………………………………………………………………………...
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Dibuat di .............
pada tanggal .............
NAMA
Kepada :
Yth. ............................................
............................................
di -
......................
SURAT PENGANTAR
NOMOR : .......................
Penerima Pengirim
Kepada :
Yth. ............................................
............................................
di -
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SURAT PENGANTAR
NOMOR : .......................
Penerima Pengirim
BERITA ACARA
NOMOR : ....................
..................................................................................................................
.........................................................................................................................
...................................
Berita Acara ini dibuat dengan sesungguhnya dalam rangkap….. untuk dipergunakan
sebagaimana mestinya.
Dibuat di ........................
NAMA NAMA
Mengetahui/Mengesahkan
NAMA
20. NOTULEN RAPAT
NOTULEN
Sidang/Rapat : ..............................................................................
Hari/Tanggal : ..............................................................................
Waktu Panggilan : ..............................................................................
Waktu sidang/rapat : ..............................................................................
Acara : 1. ..........................................................................
2. dan seterusnya
3. Penutup.
Pimpinan Sidang/Rapat
Ketua : ..............................................................................
Sekretaris : ..............................................................................
Pencatat : ..............................................................................
Peserta sidang/rapat : 1. ..........................................................................
2. dan seterusnya.
……………………………………………................................................………
.............................................................................................................
PIMPINAN SIDANG/RAPAT
NAMA PEJABAT
21. DAFTAR HADIR RAPAT
Hari : .................................................................................
Tanggal : .................................................................................
Waktu : .................................................................................
Tempat : .................................................................................
Acara : .................................................................................
1
2
3
4
5
dst
NAMA
DAFTAR HADIR
BULAN : ....................
MINGGU : ....................
SEKRETARIS
DESA/KAUR TU
DAN UMUM
NAMA
B. PENEMPATAN a.n, Plt, Plh DAN Pj
1. Penggunaan “a.n.” :
NAMA
NIP/NIAP.
2. penggunaan “Plt”:
NAMA
3. Penggunaan “Plh” :
NAMA
4. Penggunaan “Pj” :
NAMA
NAMA
PARAF HIERARKHIS
Sekdes…...
Kasi/Kaur/Kadus
*
1 cm 2,7 cm 3,8 cm 4 cm
x : PEMERINTAH KABUPATEN
xxx xx : MUARO JAMBI
xxx : KEPALA DESA ...........
xxxx
xx
x : PEMERINTAH KABUPATEN
xxx xx : MUARO JAMBI
xxx : DESA ...........
xxxx
xx
x : PEMERINTAH KABUPATEN
xxx xx : MUARO JAMBI
xxx : BPD ...........
xxxx
xx
Contoh Stempel LKD
x
x : PEMERINTAH KABUPATEN
xx : MUARO JAMBI
xxx
xxx : NAMA LKD
xxxx
xx
UKURAN HURUF.
Perbandingan huruf pada sampul naskah dinas antara tulisan nama pemerintah
daerah dan tulisan nama satuan kerja perangkat daerah adalah 3 : 4
Kepada
Nomor : ….…./….…./……/…… Yth. Sdr. .…………………
Stempel di –
…………………
Kode Pos
1. BENTUK.
Papan nama satuan kerja perangkat daerah berbentuk empat persegi panjang
berbentuk segi empat.
Contoh :
2. UKURAN.
Perbandingan ukuran huruf 3 : 4.
a. ukuran huruf “ 3 “ untuk tulisan pemerintah provinsi atau
Kabupaten Muaro Jambi.
b. ukuran huruf “ 4 “ untuk tulisan nama satuan kerja perangkat
daerah.
3. BAHAN.
1. Bahan papan nama satuan kerja perangkat daerah disesuaikan
dengan kebutuhan daerah, misalnya dari bahan kayu, beton,
seng/plat dan lain sebagainya.
2. Bahan huruf papan nama diatur sesuai kebutuhan, dapat
menggunakan cat atau dari bahan lain seperti seng/plat atau semen
dan lain sebagainya.
KECAMATAN KUMPEH
DESA SEPONJEN
PEMERINTAH KABUPATEN MUARO JAMBI
MASNAH