FORMULIR MODEL A

LAPORAN HASIL PENGAWASAN PEMILU

NOMOR : ....../LHP/PM.17.02/02/2023

I. Data Pengawas Pemilihan;

A. Tahapan yang diawasi : Pendistribusian Form C-
Pemberitahuan
B.
Nama Pelaksana Tugas : .......................................
Pengawasan
C. Jabatan : .......................................
D. Nomor Surat Perintah Tugas : ....... (dikosongi)
E. Alamat : ...................................................
II. Kegiatan Pengawasan
Kegiatan
a. Bentuk : Secara langsung.
b. Tujuan : Memastikan pendistribusian C-Pemberitahuan
sesuai dengan peraturan yang berlaku.
c. Sasaran : KPPS
D. Waktu Dan Tempat : 11-13 Februari 2024

III. Uraian Singkat Hasil Pengawasan

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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
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Kayen, 13 Februari 2024

Pelaksana Tugas

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LAMPIRAN 1

AKP Distribusi model C-Pemberitahuan

Lampiran 2

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