REKAPITULASI KLAIM BENSIN MOTOR

SUB DIVISi Booster Area I PERIODE Desember 2023

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING
1 23020789 Peni B 3836 PGL 19-Dec-23 53,167 53,207 40 Rp 15,000 Rp 90,000 DKI 11328024506
20-Dec-23 53,207 53,251 44 Rp 15,000 a/n Peni
22-Dec-23 53,251 53,334 83 Rp 15,000
27-Dec-23 53,334 53,425 91 Rp 15,000
28-Dec-23 53,425 53,471 46 Rp 15,000
29-Dec-23 53,471 53,515 44 Rp 15,000
2 23020899 Adiel Pembudi B 5545 TEM 19-Dec-23 44,203 44,247 44 Rp 15,000 Rp 90,000 DKI 11328025952
20-Dec-23 44,247 44,289 42 Rp 15,000 a/n Adiel Pembudi

21-Dec-23 44,289 44,334 45 Rp 15,000

22-Dec-23 44,334 44,379 45 Rp 15,000
28-Dec-23 44,379 44,467 88 Rp 15,000
29-Dec-23 44,467 44,514 47 Rp 15,000
3 23020914 Suripto B 5549 TEM 19-Dec-23 74,100 74,158 58 Rp 15,000 Rp 135,000 DKI 11328026061
20-Dec-23 74,158 74,243 85 Rp 15,000 a/n Suripto
21-Dec-23 74,243 74,415 172 Rp 15,000
22-Dec-23 74,415 74,492 77 Rp 15,000
25-Dec-23 74,492 74,579 87 Rp 15,000
27-Dec-23 74,579 74,644 65 Rp 15,000
28-Dec-23 74,644 74,719 75 Rp 15,000
29-Dec-23 74,719 74,795 76 Rp 15,000
30-Dec-23 74,795 74,880 85 Rp 15,000
4 23020916 Dodi Permana B 5550 TEM 19-Dec-23 35,484 35,529 45 Rp 15,000 Rp 105,000 DKI 11423014098
20-Dec-23 35,529 35,573 44 Rp 15,000 a/n Dodi Permana

21-Dec-23 35,573 35,619 46 Rp 15,000

22-Dec-23 35,619 35,660 41 Rp 15,000
27-Dec-23 35,660 35,751 91 Rp 15,000
28-Dec-23 35,751 35,796 45 Rp 15,000
29-Dec-23 35,796 35,842 46 Rp 15,000
5 23020779 Warsono B 5561 TEM 19-Dec-23 39,596 39,640 44 Rp 15,000 Rp 120,000 DKI 11328024417
20-Dec-23 39,640 39,685 45 Rp 15,000 a/n Warsono
21-Dec-23 39,685 39,730 45 Rp 15,000
22-Dec-23 39,730 39,772 42 Rp 15,000
23-Dec-23 39,772 39,816 44 Rp 15,000
27-Dec-23 39,816 39,859 43 Rp 15,000
28-Dec-23 39,859 39,905 46 Rp 15,000
29-Dec-23 39,905 39,948 43 Rp 15,000
6 301516 Kamid B 3834 PGL -
-
-
-
-
TOTAL 540,000 540,000

Prepared by : Authorizet by : Approved by :

(Disiapkan oleh) (Diperiksa oleh) (Disetujui oleh)

Ariya Mufti Suhada Bagus S Mochmad Hatta

Adm …….. Mgr…………. SM Divisi Region
 REKAPITULASI KLAIM BENSIN MOTOR
SUB DIVISi Booster Area I PERIODE Januari 2023

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING

5 23020779 Warsono B 5561 TEM 10-Jan-24 40,205 40,245 40 Rp 15,000 Rp 45,000 DKI 11328024417
11-Jan-24 40,245 40,288 43 Rp 15,000 a/n Warsono
12-Jan-24 40,288 40,333 45 Rp 15,000

TOTAL 45,000 45,000

Prepared by : Authorizet by : Approved by :

(Disiapkan oleh) (Diperiksa oleh) (Disetujui oleh)

Ariya Mufti Suhada Bagus S Mochmad Hatta

Adm …….. Mgr…………. SM Divisi Region
 REKAPITULASI KLAIM BENSIN MOTOR
SUB DIVISi Booster Area I PERIODE Januari 2023

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING

1 23020789 Peni B 3836 PGL 2-Jan-24 53,515 53,559 44 Rp 15,000 Rp 150,000 DKI 11328024506
3-Jan-24 53,559 53,601 42 Rp 15,000 a/n Peni
4-Jan-24 53,601 53,646 45 Rp 15,000
5-Jan-24 53,646 53,690 44 Rp 15,000
6-Jan-24 53,690 53,731 41 Rp 15,000
8-Jan-24 53,731 53,775 44 Rp 15,000
9-Jan-24 53,775 53,810 35 Rp 15,000
10-Jan-24 53,810 53,850 40 Rp 15,000
11-Jan-24 53,850 53,887 37 Rp 15,000
12-Jan-24 53,887 53,923 36 Rp 15,000
2 23020899 Adiel Pembudi B 5545 TEM 1-Jan-24 44,514 44,560 46 Rp 15,000 Rp 105,000 DKI 11328025952
2-Jan-24 44,560 44,604 44 Rp 15,000 a/n Adiel Pembudi
3-Jan-24 44,604 44,650 46 Rp 15,000
8-Jan-24 44,650 44,810 160 Rp 15,000
9-Jan-24 44,810 44,850 40 Rp 15,000
11-Jan-24 44,850 44,936 86 Rp 15,000
12-Jan-24 44,936 44,977 41 Rp 15,000
3 23020914 Suripto B 5549 TEM 2-Jan-24 74,880 74,965 85 Rp 15,000 Rp 135,000 DKI 11328026061
3-Jan-24 74,965 75,040 75 Rp 15,000 a/n Suripto
4-Jan-24 75,040 75,123 83 Rp 15,000
5-Jan-24 75,123 75,208 85 Rp 15,000
8-Jan-24 75,208 75,283 75 Rp 15,000
9-Jan-24 75,283 75,358 75 Rp 15,000
10-Jan-24 75,358 75,431 73 Rp 15,000
11-Jan-24 75,431 75,504 73 Rp 15,000
12-Jan-24 75,504 75,577 73 Rp 15,000
4 23020916 Dodi Permana B 5550 TEM 2-Jan-24 35,842 35,884 42 Rp 15,000 Rp 135,000 DKI 11423014098
3-Jan-24 35,884 35,928 44 Rp 15,000 a/n Dodi Permana
4-Jan-24 35,928 35,969 41 Rp 15,000
5-Jan-24 35,969 36,011 42 Rp 15,000
8-Jan-24 36,011 36,055 44 Rp 15,000
9-Jan-24 36,055 36,096 41 Rp 15,000
10-Jan-24 36,096 36,137 41 Rp 15,000
11-Jan-24 36,137 36,181 44 Rp 15,000
12-Jan-24 36,181 36,223 42 Rp 15,000
5 23020779 Warsono B 5561 TEM 2-Jan-24 39,948 39,992 44 Rp 15,000 Rp 90,000 DKI 11328024417
3-Jan-24 39,992 40,038 46 Rp 15,000 a/n Warsono
4-Jan-24 40,038 40,079 41 Rp 15,000
5-Jan-24 40,079 40,122 43 Rp 15,000
8-Jan-24 40,122 40,164 42 Rp 15,000
9-Jan-24 40,164 40,205 41 Rp 15,000
TOTAL 615,000 615,000

Prepared by : Authorizet by : Approved by :

(Disiapkan oleh) (Diperiksa oleh) (Disetujui oleh)

Ariya Mufti Suhada Bagus S Mochmad Hatta

Adm …….. Mgr…………. SM Divisi Region
 REKAPITULASI KLAIM BENSIN MOTOR
SUB DIVISi Booster Area I PERIODE Januari 2023

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING

1 23020789 Peni B 3836 PGL 15-Jan-24 53,923 53,969 46 Rp 15,000 Rp 120,000 DKI 11328024506
16-Jan-24 53,969 54,011 42 Rp 15,000 a/n Peni
17-Jan-24 54,011 54,051 40 Rp 15,000
22-Jan-24 54,097 54,187 90 Rp 15,000
23-Jan-24 54,187 54,233 46 Rp 15,000
24-Jan-24 54,233 54,281 48 Rp 15,000
25-Jan-24 54,281 54,323 42 Rp 15,000
26-Jan-24 54,323 54,368 45 Rp 15,000
2 23020934 Galih Abdul Baaqii B 5545 TEM 15-Jan-24 44,977 45,023 46 Rp 15,000 Rp 120,000 DKI 11428002039
16-Jan-24 45,023 45,070 47 Rp 15,000
a/n Galih Abdul Baaqii
17-Jan-24 45,070 45,112 42 Rp 15,000
18-Jan-24 45,112 45,162 50 Rp 15,000
19-Jan-24 45,162 45,207 45 Rp 15,000
22-Jan-24 45,207 45,249 42 Rp 15,000
23-Jan-24 45,249 45,290 41 Rp 15,000
26-Jan-24 45,290 45,421 131 Rp 15,000
3 23020914 Suripto B 5549 TEM 15-Jan-24 75,577 75,662 85 Rp 15,000 Rp 150,000 DKI 11328026061
16-Jan-24 75,662 75,748 86 Rp 15,000 a/n Suripto
17-Jan-24 75,748 75,835 87 Rp 15,000
18-Jan-24 75,835 75,921 86 Rp 15,000
19-Jan-24 75,921 76,006 85 Rp 15,000
22-Jan-24 76,006 76,093 87 Rp 15,000
23-Jan-24 76,093 76,188 95 Rp 15,000
24-Jan-24 76,188 76,284 96 Rp 15,000
25-Jan-24 76,284 76,369 85 Rp 15,000
26-Jan-24 76,369 76,456 87 Rp 15,000
4 23020916 Dodi Permana B 5550 TEM 15-Jan-24 36,223 36,270 47 Rp 15,000 Rp 150,000 DKI 11423014098
16-Jan-24 36,270 36,312 42 Rp 15,000 a/n Dodi Permana
17-Jan-24 36,312 36,356 44 Rp 15,000
18-Jan-24 36,356 36,398 42 Rp 15,000
19-Jan-24 36,398 36,448 50 Rp 15,000
22-Jan-24 36,448 36,490 42 Rp 15,000
23-Jan-24 36,490 36,540 50 Rp 15,000
24-Jan-24 36,540 36,582 42 Rp 15,000
25-Jan-24 36,582 36,623 41 Rp 15,000
26-Jan-24 36,623 36,664 41 Rp 15,000
5 23020779 Warsono B 5561 TEM 10-Jan-24 40,205 40,245 40 Rp 15,000 Rp 195,000 DKI 11328024417
11-Jan-24 40,245 40,288 43 Rp 15,000 a/n Warsono
12-Jan-24 40,288 40,333 45 Rp 15,000
15-Jan-24 40,333 40,378 45 Rp 15,000
16-Jan-24 40,333 40,421 88 Rp 15,000
17-Jan-24 40,421 40,462 41 Rp 15,000
18-Jan-24 40,462 40,503 41 Rp 15,000
19-Jan-24 40,503 40,552 49 Rp 15,000
22-Jan-24 40,552 40,593 41 Rp 15,000
23-Jan-24 40,593 40,633 40 Rp 15,000
24-Jan-24 40,633 40,682 49 Rp 15,000
25-Jan-24 40,682 40,726 44 Rp 15,000
26-Jan-24 40,726 40,775 49 Rp 15,000
TOTAL Rp 735,000 Rp 735,000

Prepared by : Authorizet by : Approved by :

(Disiapkan oleh) (Diperiksa oleh) (Disetujui oleh)

Ariya Mufti Suhada Bagus S Mochmad Hatta

Admin Manager Senior Manager
 REKAPITULASI KLAIM BENSIN MOTOR
SUB DIVISi Booster Area I PERIODE Januari 2023

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING

5 23020779 Warsono B 5561 TEM 16-Jan-24 40,333 40,421 Rp 15,000 Rp 135,000 DKI 11328024417
17-Jan-24 40,421 40,462 Rp 15,000 a/n Warsono
18-Jan-24 40,462 40,503 Rp 15,000
19-Jan-24 40,503 40,552 Rp 15,000
22-Jan-24 40,552 40,593 Rp 15,000
23-Jan-24 40,593 40,633 Rp 15,000
24-Jan-24 40,633 40,682 Rp 15,000
25-Jan-24 40,682 40,726 Rp 15,000
26-Jan-24 40,726 40,775 Rp 15,000

135,000 135,000

0
 REKAPITULASI KLAIM BENSIN MOTOR
SUB DIVISi Booster Area I PERIODE Febuari 2024

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING

1 23020789 Peni B 3836 PGL 29-Jan-24 54,363 54,407 44 Rp 15,000 Rp 195,000 DKI 11328024506
30-Jan-24 54,407 54,455 48 Rp 15,000 a/n Peni
31-Jan-24 54,455 54,501 46 Rp 15,000
1-Feb-24 54,501 54,550 49 Rp 15,000
2-Feb-24 54,550 54,600 50 Rp 15,000
5-Feb-24 54,600 54,648 48 Rp 15,000
6-Feb-24 54,648 54,695 47 Rp 15,000
7-Feb-24 54,695 54,739 44 Rp 15,000
12-Feb-24 54,739 54,786 47 Rp 15,000
13-Feb-24 54,786 54,835 49 Rp 15,000
15-Feb-24 54,835 54,882 47 Rp 15,000
16-Feb-24 54,882 54,928 46 Rp 15,000
17-Feb-24 54,928 54,977 49 Rp 15,000
2 23020899 Adiel Pembudi B 5545 TEM 30-Jan-24 45,421 45,469 48 Rp 15,000 Rp 135,000 DKI 11328025952
31-Jan-24 45,469 45,518 49 Rp 15,000 a/n Adiel Pembudi
1-Feb-24 45,518 45,565 47 Rp 15,000
2-Feb-24 45,565 45,614 49 Rp 15,000
5-Feb-24 45,614 45,661 47 Rp 15,000
6-Feb-24 45,661 45,711 50 Rp 15,000
12-Feb-24 45,711 45,758 47 Rp 15,000
15-Feb-24 45,758 45,807 49 Rp 15,000
16-Feb-24 45,807 45,853 46 Rp 15,000
3 23020914 Suripto B 5549 TEM 29-Jan-24 76,456 76,541 85 Rp 15,000 Rp 195,000 DKI 11328026061
30-Jan-24 76,541 76,628 87 Rp 15,000 a/n Suripto
31-Jan-24 76,628 76,714 86 Rp 15,000
1-Feb-24 76,714 76,801 87 Rp 15,000
2-Feb-24 76,801 76,890 89 Rp 15,000
5-Feb-24 76,890 76,977 87 Rp 15,000
6-Feb-24 76,977 77,067 90 Rp 15,000
7-Feb-24 77,067 77,162 95 Rp 15,000
12-Feb-24 77,162 77,257 95 Rp 15,000
13-Feb-24 77,257 77,352 95 Rp 15,000
15-Feb-24 77,352 77,446 94 Rp 15,000
16-Feb-24 77,446 77,543 97 Rp 15,000
17-Feb-24 77,543 77,638 95 Rp 15,000
4 23020916 Dodi Permana B 5550 TEM 30-Jan-24 36,664 36,712 48 Rp 15,000 Rp 195,000 DKI 11423014098
31-Jan-24 36,712 36,759 47 Rp 15,000 a/n Dodi Permana
1-Feb-24 36,759 36,809 50 Rp 15,000
2-Feb-24 36,809 36,856 47 Rp 15,000
4-Feb-24 36,856 36,906 50 Rp 15,000
5-Feb-24 36,906 36,950 44 Rp 15,000
6-Feb-24 36,950 36,994 44 Rp 15,000
7-Feb-24 36,994 37,042 48 Rp 15,000
12-Feb-24 37,042 37,091 49 Rp 15,000
13-Feb-24 37,091 37,138 47 Rp 15,000
15-Feb-24 37,138 37,187 49 Rp 15,000
16-Feb-24 37,187 37,237 50 Rp 15,000
17-Feb-24 37,237 37,279 42 Rp 15,000
5 23020779 Warsono B 5561 29-Jan-24 40,333 40,421 88 Rp 15,000 Rp 210,000 DKI 11328024417
30-Jan-24 40,421 40,465 44 Rp 15,000 a/n Warsono
31-Jan-24 40,465 40,513 48 Rp 15,000
1-Feb-24 40,513 40,558 45 Rp 15,000
2-Feb-24 40,558 40,604 46 Rp 15,000
4-Feb-24 40,604 40,652 48 Rp 15,000
5-Feb-24 40,652 40,696 44 Rp 15,000
6-Feb-24 40,696 40,738 42 Rp 15,000
8-Feb-24 40,738 40,782 44 Rp 15,000
9-Feb-24 40,782 40,827 45 15,000
12-Feb-24 40,827 40,871 44 15,000
13-Feb-24 40,871 40,914 43 15,000
16-Feb-24 40,914 40,962 48 15,000
17-Feb-24 40,962 41,009 47 15,000
TOTAL 930,000 930,000

Prepared by : Authorizet by : Approved by :

(Disiapkan oleh) (Diperiksa oleh) (Disetujui oleh)

Ariya Mufti Suhada Bagus S Mochmad Hatta

Admin Manager Senior Manager
 REKAPITULASI KLAIM BENSIN MOTOR
SUB DIVISi Booster Area I PERIODE Febuari 2024

NO NPP NAMA NO POL TANGGAL KM AWAL KM AKHIR TOTAL KM NOMINAL TOTAL CLAIM BANK NOMOR REKENING

1 23020789 Peni B 3836 PGL 19-Feb-24 54,997 55,042 45 Rp 15,000 Rp 60,000 11328024506
20-Feb-24 55,042 55,088 46 Rp 15,000 a/n Peni
21-Feb-24 55,088 55,130 42 Rp 15,000
23-Feb-24 55,130 55,176 46 Rp 15,000

2 23020899 Adiel Pembudi B 5545 TEM 19-Feb-24 45,853 45,897 44 Rp 15,000 Rp 60,000 11328025952
20-Feb-24 45,897 45,943 46 Rp 15,000 a/n Adiel Pembudi
22-Feb-24 45,943 45,989 46 Rp 15,000
23-Feb-24 45,989 46,031 42 Rp 15,000

3 23020914 Suripto B 5549 TEM 19-Feb-24 77,638 77,723 85 Rp 15,000 Rp 90,000 DKI 11328026061
20-Feb-24 77,723 77,811 88 Rp 15,000 a/n Suripto
21-Feb-24 77,811 77,900 89 Rp 15,000
22-Feb-24 77,900 77,987 87 Rp 15,000
23-Feb-24 77,987 78,075 88 Rp 15,000
26-Feb-24 78,075 78,164 89 Rp 15,000

4 23020916 Dodi Permana B 5550 TEM 20-Feb-24 37,279 37,326 47 Rp 15,000 Rp 105,000 DKI 11423014098
21-Feb-24 37,326 37,366 40 Rp 15,000 a/n Dodi Permana
22-Feb-24 37,366 37,415 49 Rp 15,000
23-Feb-24 37,415 37,460 45 Rp 15,000
24-Feb-24 37,460 37,504 44 Rp 15,000
25-Feb-24 37,504 37,544 40 Rp 15,000
26-Feb-24 37,544 37,591 47 Rp 15,000

5 23020779 Warsono B 5561 TEM 15-Feb-24 41,009 41,050 41 Rp 15,000 Rp 105,000 DKI 11328024417
19-Feb-24 41,050 41,097 47 Rp 15,000 a/n Warsono
20-Feb-24 41,097 41,140 43 Rp 15,000
21-Feb-24 41,140 41,181 41 Rp 15,000
22-Feb-24 41,181 41,229 48 Rp 15,000
23-Feb-24 41,229 41,272 43 Rp 15,000
24-Feb-24 41,272 41,322 50 Rp 15,000

TOTAL 420,000 Err:522

Prepared by : Authorizet by : Approved by :

(Disiapkan oleh) (Diperiksa oleh) (Disetujui oleh)

Ariya Mufti Suhada Bagus S Mochmad Hatta

Admin Manager Senior Manager
 REKAPITULASI BENSIN MOTOR DIVISI/SUB DIVISI
BULAN ……. 2023

No NAMA NPP Divisi Sub Divisi Nomor Motor

Jumlah yang
BANK No Rekening
TOTAL
diterima

1 XXXXX XXXXX DKI

XXXXX XXXXX XXXXXX 500,000

2 DKI

3 DKI

4 DKI

5 DKI Rp 500,000

6 DKI

7 DKI

8 DKI

9 DKI

10 DKI

11 DKI

12 DKI

13 DKI

14 DKI

15 DKI

16 DKI Rp -

17 DKI Rp -

18 DKI

19 DKI

20 DKI

21 DKI

22 DKI

23 DKI Rp -

24 DKI
 REKAPITULASI BENSIN MOTOR DIVISI/SUB DIVISI
BULAN ……. 2023

No NAMA NPP Divisi Sub Divisi Nomor Motor

Jumlah yang
BANK No Rekening
TOTAL
diterima

25 DKI

26 DKI

27 DKI

28 DKI

29 DKI Rp -

30 DKI

31 DKI

32 DKI

33 DKI

34 DKI

35 DKI Rp -

36 DKI

37 DKI

38 DKI

39 DKI

40 DKI

41 DKI Rp -

TOTAL Rp 500,000 Rp 500,000

Membuat Mengetahui Menyetujui

Admin Manager Senior Manager

 PERUMDA AIR MINUM JAYA No. : PAM/ACF/SOP-001-FRM-009
FORMULIR Revisi : 00
Tanggal Berlaku : 05 May 2023
FORMULIR CHECKLIST KELENGKAPAN DAN PENERIMAAN DOKUMEN PENAGIHAN PAM
JAYA (Internal) Halaman 1 dari 1

Nama Divisi :
No Surat Permohonan Pembayaran : 27703/KU.01.08
Nama Kegiatan : Claim Bensin Bulan Desember 2023
Jumlah Tagihan 500,000

No JenisDokumen Status Keterangan

1 Surat Permohonan Pembayaran √

2 TNDE / Disposisi Persetujuan Surat Permohonan Pembayaran

3 Kwitansi Bermeterai (Diatas Rp 5.000.000)

4 Faktur Pajak (**)
5 Surat Non PKP (**)
6 Surat Tugas (*)
7 RAB Rencana Anggaran Biaya (*)
8 Proposal/tagihan dari pihak ketiga (**)
9 Dokumen Pendukung Lainnya (**) √ Surat dan Lampiran

(*) Untuk Perjalanan Dinas/ Diklat/Kegiatan Divisi/Pembelian Barang Langsung

(**) Jika ada

Catatan: Anggaran (Wajib di isi User)

Directorat Pelayanan
Diterima
Divisi
Diterima, dengan catatan : Kode Analytic Account (Kode AA)

Ditolak, dengan catatan : Kode Mata Anggaran

Kode Kegiatan

SM Divisi Terkait Penerima,

Nama: Nama:
Tanggal: Tanggal:

NOTE :
Dengan di tandatanganinya formulir checklist ini, maka kami menyatakan bahwa telah memeriksa dokumen dengan benar dan lengkap serta sesuai
dengan Komitmen Bersama Kebijakan Anti Penyuapan PAM JAYA.