BADAN PERMUSYAWARATAN DESA

DESA.....................
KECAMATAN.............. KABUPATEN SITUBONDO
Jln. ............ No. ........ Telp:……………… Kode Pos: ……

BERITA ACARA
MUSYAWARAH BADAN PERMUSYAWARATAN DESA (BPD)

TENTANG
PERGANTIAN ANTAR WAKTU (PAW) ANGGOTA BPD
DUSUN .......... DESA .......... KECAMATAN ...........
KABUPATEN SITUBONDO

Berkaitan dengan pelaksanaan musyawarah Badan Permusyawaratan

Desa tentang pergantian antar waktu anggota BPD Dusun ............
Desa ........... Kecamatan ............ Kabupaten Situbondo Provinsi Jawa Timur,
maka pada hari ini:
Hari dan Tanggal : .............. dan ......................... 20...
Jam : ..................... WIB - selesai
Tempat : Kantor Sekretariat BPD
telah diselenggarakan kegiatan musyawarah pergantian antar waktu anggota
BPD Dusun .......... Desa .......... oleh anggota BPD, wakil-wakil kelompok,
dusun dan tokoh masyarakat, serta unsur lain yang terkait Desa sebagaimana
tercantum dalam daftar hadir terlampir.
Materi yang dibahas, serta yang bertindak selaku unsur pimpinan
musywarah dan narasumber dalam membahas antar waktu anggota BPD
Dusun .......... sebagimana dimaksud pada poin diatas, adalah:
A. Materi
1. Sambutan Kepala Desa .......... ;
2. Sambutan Ketua BPD .......... ;
3. Penjelasan tata cara prosedur PAW Anggota BPD;
4. Penandatangan berita acara; dan
5. Penutup.
B. Unsur Pimpinan Rapat dan Narasumber
Pemimpin Musyawarah : …..…………………….............. dari Ketua BPD
Notulen : …..…………………….............. dari Sekr. BPD
Narasumber : 1. …..…………………….......... dari ..............
2. …..…………………….......... dari ..............
3. ....dan seterusnya. dari ..............

Setelah dilakukan pembahasan dan diskusi terhadap materi,

selanjutnya seluruh peserta musyawarah BPD menyepakati beberapa hal yang
berketetapan menjadi kesepakatan akhir dari musyawarah BPD tentang
pergantian antar waktu anggota BPD Dusun .......... Desa .......... yaitu:
1. ....................................................................................................................
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2. ....................................................................................................................
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5. ....................................................................................................................
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Keputusan diambil secara musyawarah mufakat/aklamasi dan

pemungutan suara/voting.

Demikian berita acara msuyawarah BPD ini dibuat dan disahkan

dengan penuh tanggungjawab agar dapat dipergunakan sebagaimana
mestinya.

....nama desa, ..... - ..... – 20....

Pimpinan Musyawarah, Sekretaris/Notulis,

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

Mengetahui,
Kepala Desa, Ketua BPD,

Nama, tanda tangan & cap Nama, tanda tangan & cap
.......................................... ..........................................

Wakil Masyarakat,
..........................................
 NOTULENSI

Agenda Kegiatan : Musyawarah BPD tentang Pergantian Antar Waktu (PAW)

anggota BPD Dusun .............. Desa ........
Hari dan Tanggal : ……………… dan ……...……… 20...
Jam : ...... WIB – selesai.
Notulen:

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....nama desa, ..... - ..... – 20...

Notulis,

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 DAFTAR HADIR
MUSYAWARAH BADAN PERMUSYAWARATAN DESA (BPD)

TENTANG
PERGANTIAN ANTAR WAKTU (PAW) ANGGOTA BPD
DUSUN .......... DESA .......... KECAMATAN ...........
KABUPATEN SITUBONDO

Hari/Tanggal : ............., ....................... 20...

Jam : .................... WIB
Tempat : ................................................
Jumlah Peserta : .............. orang
Laki-laki : ................ orang, Perempuan : ................ orang
JABATAN/ TANDA
NO NAMA L/P ALAMAT
UNSUR TANGAN
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NO NAMA L/P ALAMAT
UNSUR TANGAN
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....nama desa, ..... - ..... – 20...

Kepala Desa .................. Ketua BPD,

Nama, tanda tangan & cap Nama, tanda tangan & cap
.......................................... ..........................................