1.

FORMULIR A BAGI PENGAWAS TPS

FORMULIR MODEL.A
LAPORAN HASIL PENGAWAS PEMILU
Nomor: 001 /LHP/PM.01.00/02/2024

I. DATA PENGAWAS PEMILU

1. Tahapan yang diawasi :............................................................................
2. Nama Pelaksana Tugas :............................................................................
3. Jabatan :............................................................................
4. Nomor Surat Perintah Tugas:...........................................................................
5. Alamat :............................................................................

II. KEGIATAN PENGAWASAN

1. Bentuk :...........................................................................
2. Tujuan :............................................................................
3. Sasaran :............................................................................
4. Waktu dan Tempat :............................................................................

III. URAIAN SINGKAT HASIL PENGAWASAN (UPAYA PENCEGAHAN,

SASARAN PERBAIKAN
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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 :............................................................................
b. Alamat :............................................................................
c. Nama :............................................................................
d. Alamat :............................................................................

3. Alat Bukti
a. ........................................................................................................................
b. ........................................................................................................................
c. ........................................................................................................................

4. Barang Bukti
a.........................................................................................................................
b........................................................................................................................
c.........................................................................................................................

5. Uraian Singkat dugaan pelanggaran

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Padangsidimpuan, Februari 2024

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