Bagi_word_formulir_swakelola.doc

CONTOH FORMAT

DAFTAR LAMPIRAN

Lampiran 1

: MEMORANDUM of UNDERSTANDING (MoU) (TEMPLATE SWAKELOLA - 1)

Lampiran 2

: SURAT PERANIAN PERANIA N SWAKELO SWAKELOLA LA (TEMPLATE SWAKELOLA - 2)

Lampiran !

: SURAT PENUGASAN"PEM#ENTUKAN TIM (TEMPLATE SWAKELOLA - !)

Lampiran $a

: KERANGKA A%UAN KERA"PROPOSAL TEKNIS PEKERAAN &ISIK (#ANGUNAN) (TEMPLATE SWAKELOLA - $a)

Lampiran $' : KERANGKA A%UAN KERA PEKERAAN LAINNA (TEMPLATE (TEMPLAT E SWAKELOLA $') Lampiran 

: GAM#AR REN%ANA DAN SPESI&IKASI TEKNIS PEKERAAN (&ORM

SW -

) Lampiran *

: ADUAL PELAKSANAAN PEKERAAN"KEGIATAN (TEMPLATE SWAKELOLA - *)

Lampiran +

: ADUAL PENGADAAN"KE#UTU,AN #A,AN TENAGA KERA DAN PERALATAN (TEMPLATE SWAKELOLA - +)

Lampiran .

: REN%ANA ANGGARAN #IAA (RA#) (TEMPLATE SWAKELOLA - .)

Lampiran /

: SK PENGANGKATAN PANITIA PENGADAAN (TEMPLATE SWAKELOLA - /)

Lampiran 10a : LAPORAN ,ASIL SUREI DAN PENGUKURAN &ISIK (TEMPLATE SWAKELOLA - 10a) Lampiran 10' : LAPORAN ,ASIL SUREI DAN KONDISI PEKERAAN LAINNA (TEMPLATE SWAKELOLA - 10') Lampiran 11 : SURAT PENGAUAN KE#UTU,AN #A,AN"MATERIAL TENAGA KERA DAN PERALATAN (&ORM SM - 11) Lamp Lampir iran an 12a 12a : KONTRAK"PERANIAN PENGADAAN #ARANG"#A,AN (&ORM

SW -

12a) Lamp Lampir iran an 12' 12' : KONTRAK"PERANIAN TENAGA A,LI ORANG PERSEORANGAN (&ORM SW - 12') Lamp Lampir iran an 12 12 : KONTRAK KERA ORANG PERSEORANGAN #ORONGAN (TEMPLATE SWAKELOLA 12) Lampiran 1! : LAPORAN PENERIMAAN DAN PENGGUNAAN #A,AN"MATERIAL TENAGA KERA DAN DAN PERALATAN (&ORM SM - 1!) Lampiran 1$a : LAPORAN ,ARIAN (TEMPLATE SWAKELOLA - 1$a) Lampiran 1$' : LAPORAN MINGGUAN (TEMPLATE SWAKELOLA - 1$')

54

CONTOH FORMAT

Lampiran 1$ : LAPORAN #ULANAN (TEMPLATE SWAKELOLA - 1$) Lampiran 1 : SURAT PERMINTAAN UNTUK U NTUK PEM#AARA PEM#AARAN N (TEMPLATE SWAKELOLA - 1) Lampiran 1* : DA&TAR ,ADIR (TEMPLATE SWAKELOLA - 1*) Lampiran 1+ : PEM#AARAN #A,AN"MATERIAL DAN PERALATAN (TEMPLATE SWAKELOLA 1+) Lampiran 1. : PANAR KERA (TEMPLATE SWAKELOLA - 1.) Lampiran 1/a : REALISASI PEKERAAN &ISIK (TEMPLATE SWAKELOLA - 1/a) Lampiran 1/' : REALISA REALISASI SI PEKERAAN LAINNA (TEMPLATE SWAKELOLA - 1/a) Lampiran 20 : LAPORAN PEKERAAN SELESAI SELES AI (TEMPLATE SWAKELOLA SWAKEL OLA - 20) Lampiran Laporan P343r5aan S3637ai (Lampiran 1) Lampiran Laporan P343r5aan S3637ai (Lampiran 2) Lampiran 21 : #ERITA A%ARA PENERA,AN PEKERAAN SELESAI (TEMPLATE SWAKELOLA 21) Lampiran 22 : LEM#AR PENGAWASAN"DA&TAR SIMAK (TEMPLATE SWAKELOLA - 22) Lampiran 2! : SURAT PENUGASAN UNTUK PEMERIKSAAN PEMERIKSAAN DAN EALUASI (&ORM SW 2!)

55

CONTOH FORMAT

Lampiran 1 : MEMORANDUM of UNDERSTANDING (MoU) (TEMPLATE SWAKELOLA - 1) KOP SURAT

NASKA, KESEPAKATAN KERASAMA an8ara 999999999999999999 ;3n6an '>6an 999 999 8a=>n 8a=>n 9999 9999 '3r83mpa8 '3r83mpa8 ;i 99 4ami ?an< '3r8an;a 8an8n?a ;i73'>8 73'a8n?a ;i73'>8 73'a
PI,AK PERTAMA ;an PI,AK KEDUA 73ara '3r7ama-7ama m3n?a8a4an 73pa4a8 ;an 738>5> >n8>4 m3m'>a8 Na74a= K373pa4a8an K3r5a7ama ;3nan 73'a8 :

TUUAN KERASAMA Pa7a6 1 Na74a= K373pa4a8an K3r5a7ama '3r8>5>an >n8>4 m3nin<4a84an 4>a6i8a7 p36a47anaan 8>n<7i ma7in<-ma7in< pi=a4 737>ai 43@3nan
RUANG LINGKUP KERASAMA Pa7a6 2 Na74a= Na74a= K373pa4a K373pa4a8an 8an K3r5a7ama K3r5a7ama 73'a;4an ;ima47>;4an ;a6am ;a6am pa7a6 1 (7a8>) ;i a8a7 m3na4>p 43
56

CONTOH FORMAT

9999999999999999999999999999999999999  

PELAKSANAAN KEGIATAN Pa7a6 ! K373pa4a8an K3r5a7ama ini a4an ;i8in;a46an5>8i ;an ;ia8>r ;a6am 7>ra8 p3r5an5ian 83r73n;iri ?an< ;i'>a8 o63= PI,AK PERTAMA ;an PI,AK KEDUA a8a> o63= p35a'a8 ?an< ;i8>n5>4 ;an ;i'3ri @3@3nan< o63= 43;>a '36a= pi=a4 >n8>4 m36a47ana4an =a6 83r73'>8

PEM#IAAAN Pa7a6 $ P3m'ia?aan ?an< 8im'>6 73'ar ;an ;i8>an<4an ;a6am P3r5an5ian P36a47anaan K3r5a7ama ?an< a4an ;i7>7>n 63'i= 6an5>8 ;an ;i8an;a8ann5>4 " ;i8>
ANGKA WAKTU Pa7a6  Na74a= K373pa4a8an K3r5a7ama ini '3r6a4> >n8>4 5an<4a @a48> 83r=i8>n< 735a4 ;i8an;a8an'a= ma>p>n ;ia4=iri a8a7 p3r738>5>an 43;>a '36a= pi=a4

PENUTUP Pa7a6 * 1 Na74a= K373pa4a8an K3r5a7ama ini ;i'>a8 ;a6am ran<4ap 2 (;>a) a76i ma7in<-ma7in< '3rma83rai >4>p 73r8a m3mp>n?ai 434>a8an =>4>m ?an< 7ama 73836a= ;i8an;a8ana '36a= pi=a4 ;an ;i'>'>=i ap 63m'am ;ia8>r ;a6am Na74a= K373pa4a8an K3r5a7ama ini a4an ;ia8>r 43m>;ian a8a7 p3r738>5>an 43;>a '36a= pi=a4 ! Na74a= K373pa4a8an K3r5a7ama ini m>6ai '3r6a4> 735a4 ;i8an;a8anan 'a=@a 73a8>n?a a4an ;ip3r'ai4i 73'a;ian =ari 83r;apa8 43436ir>an PI,AK KEDUA

PI,AK PERTAMA

999999999999999

999999999999999

 NIP 

 NIP 

57

CONTOH FORMAT

Lampiran  : SURAT PER!AN!IAN SWAKELOLA (TEMPLATE SWAKELOLA - ) KOP SURAT

SURAT PER!AN!IAN SWAKELOLA ANTARA K"L"D"I ########################################################## D$n%an ILPS ##########################################################

Nomor : &&&&&&&&&&&&&&&& Tan%%a' : &&&&&&&&&&&&&&&& T3n8an< &&&&&&&&&&&&&&&&&&&&&&&#

SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an6an  8a=>n  an8ara   736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama K"L"D"I   ?an< '3r43;>;>4an ;i  No# #### T$'p# (########################) ################  '3r;a7ar4an S>ra8 K3p>8>7an 9999999999 No 999999999 (736an5>8n?a ;i73'>8  P ia) I B) ;an #######################  D$an Fa*'+a, ####################################################  ?an< '3r8in;a4 >n8>4 ;an a8a7 nama Fa*'+a, ###################################################################  ?an< '3r43;>;>4an ;i ######################################################  ( Pia) II B)

MENGINGAT #A,WA: (a)

Pia I 836a= m3min8a Pia II >n8>4 m36a47ana4an 438n?a ;i73'>8 P$$r.aan S/a$'o'aB)C

58

CONTOH FORMAT

(')

Pia II 73'am'3r ;a?a 834ni7 73r8a 836a= m3n?38>5>i >n8>4 m36a47ana4an p$$r.aan ,/a$'o'a 737>ai ;3nan ;a6am Kon+ra) iniC

()

Pia I ;an Pia II m3n?a8a4an m3mi6i4i 43@3nann8>4 m3nan;a8an
(;)

Pia I ;an Pia II m3ni ;an m3n?a8a4an 'a=@a 73=>'>nn8>4 ;i;ampin8C !) 836a= m3m'aa ;an m3ma=ami 73ara p3n>= 4383n8>an Kon8ra4 iniC $) 836a= m3n;apa84an 4373mpa8an ?an< m3ma;ai >n8>4 m3m3ri47a ;an m3n<4onfirma7i4an 73m>a 4383n8>an ;a6am Kon8ra4 ini '373r8a 73m>a fa48a ;an ;an 4on;i7i ?an< 83r4ai8

MAKA OLE, KARENA ITU Pia I ;an Pia II ;3n5>i =a6=a6 73'a8: 1

P343r5aan ?an< ;ima47>; ;a6am 4on8ra4 ini a;a6a= P36a47anaan 99999999999999999999999999999999999999999999999

2

To8a6 Ni6ai Kon8ra4 a;a6a= 73'37ar ()C

!

p3ri78i6a=an ;an >n<4apan ;a6am S>ra8 P3r5an5ian ini m3mi6i4i ar8i ;an ma4na ?an< 7ama 73p3r8i ?an< 83ran8>m ;a6am 6ampiran S>ra8 P3r5an5ian iniC

$

;o4>m3n-;o4>m3n '3ri4>8 (736an5>8n?a ;i73'>8 Do*m$n Kon+ra B) m3r>pa4an 7a8>-437a8>an ;an 'aan K3r5a (KAK)  Daf8ar 4>an8i8a7 ;an =arm3n 6ainn?a 73p3r8i: 5aminan-5aminan SPP# #A,P (apa'i6a a;a)



Do4>m3n Kon8ra4 ;i'>a8 >n8>4 7a6in< m3n536a74an 7a8> 7ama 6ain ;an 5i4a 83r5a;i p3r83n8anan ;a6am 7>a8> ;o4>m3n ;3nan ;a6am ;o4>m3n ?an< 6ain ma4a ?an< '3r6a4> a;a6a= 4383n8>an ;a6am ;o4>m3n ?an< 63'i= 8in<r>8an =i3rar4i pa;a an<4a ! ;i a8a7C



,a4 ;an 43@a5i'an 8im'a6-'a6i4 PI,AK I ;an Pi=a4 II ;in?a8a4an ;a6am Kon8ra4 ?an< m36ip>8i 4=>7>7n?a : a. PI,AK I m3mp>n?ai =a4 ;an 43@a5i'an >n8>4 : 1) m3n4an o63= Pi=a4 IIC

Rp



59

CONTOH FORMAT

!)

b.

*

m3m'a?ar p343r5aan 737>ai ;3nm ;a6am Kon8ra4 ?an< 836a= ;i838ap4an 43pa;a Pi=a4 IIC

Pi=a4 II m3mp>n?ai =a4 ;an 43@a5i'an >n8>4 : 1) m3n3rima p3m'a?aran >n8>4 p36a47anaan p343r5aan 737>ai ;3n4an ;a6am Kon8ra4C 2) m36apor4an p36a47anaan p343r5aan 73ara p3rio;i4 43pa;a PI,AK IC !) m36a47ana4an ;an m3n?3637ai4an p343r5aan 737>ai ;3nra8 ;an p3n>= 8an<<>n< 5a@a' ;3n8an 43 a8a> ;ari 6apanp>n 73m3n8ara ?an< ;ip3r6>4an >n8>4 p36a47anaan p3n?3637aian ;an p3r'ai4an p343r5aan ?an< ;irini ;a6am Kon8ra4C ) m3m'3ri4an 4383ran4an >n8>4 p3m3ri47aan p36a47anaan ?an< ;i6a4>4an PI,AK IC *) m3n?3ra=4an =a7i6 p343r5aan 737>ai ;3n
Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<m3n Kon8ra4 ;3n6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'ar ;a6am Do4>m3n Kon8ra4

DENGAN DEMIKIAN PI,AK I ;an Pi=a4 II 836a= '3r73pa4a8 >n8>4 m3nan;a8an8 ;i a8a7 ;an m36a47ana4an Kon8ra4 737>ai ;3nan p3ra8>ran p3r>n;an<->n;an'6i4 In;on37ia

Un8>4 ;an a8a7 nama PI,AK I

Un8>4 ;an a8a7 nama Pi=a4 II

##########################################

##########################################

NIP# #########################################

NIP# #########################################

60

CONTOH FORMAT

Lampiran 0 : SURAT PENUGASAN"PEMENTUKAN TIM (TEMPLATE SWAKELOLA 0)

KOP SURAT

KEPUTUSAN PE!AAT PEMUAT KOMITMEN KEGIATAN ################################################################## SATUAN KER!A ###################################################################### ####################################################################################################### K"L"D"I #################################### NOMOR : ################################### TENTANG PEMENTUKAN TIM KEGIATAN SWAKELOLA KEGIATAN ############################################################################## ############################################################################################# K"L"D"I ################################### TA2UN ANGGARAN ########

M$nim3an%

: a

#a=@a >n8>4 m3n ;i'3n8>4 Tim S@a436o6a ' #a=@a para P35a'a8"P38> ;an m3m3n>=i 7?ara8 >n8>4 m36a47ana4an 8>n8>4 ma47>; 83r73'>8 ma4a p3r6> ;i436>ar4an S>ra8 P3m'3n8>4an"P3n>
M$n%in%a+

: 1

P3ra8>ran Pr37i;3n R3p>'6i4 In;on37ia No $ Ta=>n 2010 T3n8an< P3n8>7an 9C ! 9999999999999999999999999999 999999C $ 99999999999999999999999999999 999;78 MEMUTUSKAN

M$n$+apan K$,a+*

: : M3m'3n8>4 Tim 7@a436o6a ?an< 83r;iri ;ari Tim P3r3nana Tim P36a47ana ;an Tim P3n7>nan 73'a8 :

61

CONTOH FORMAT

Tim P3r3nana : 1 S;r 9999999999999999999999973'aa TimC 2 S;r 9999999999999999999973'a4 S@a436o6a Tip3 2: In78an7i P3m3rin8a= Lain Tim P36a47ana ;i838ap4an o63= In78an7i P36a47ana S@a436o6a) 1 S;r 9999999999999999999999973'aa TimC 2 S;r 9999999999999999999973'aa TimC 2 S;r 9999999999999999999973'a
: Tim P3r3nana K3n?ai 8>n< 5a@a' 73'a8 : 1 a ' 2 a ' ! a

########################( K38>a Tim)  C  C #########################( S34r38ari7 Tim)  C  C #########################( An<
62

CONTOH FORMAT

C '  ;78C Tim P36a47ana K3n?ai 8>n< 5a@a' 73'a8 : (Un8>4 S@a436o6a Tip3 2: In78an7i P3m3rin8a= Lain Tim P36a47ana ;i838ap4an o63= In78an7i P36a47ana S@a436o6a) 1 a ' 2 a ' ! a '

Tim P3nn?ai 8>n< 5a@a' 73'a8 : 1 a ' 2 a ' ! a '

K$+i%a

: K3pa;a 8im p3r3nana 8im p36a47ana ;an 8im p3nm 737>ai 43;>;>4ann?a ;a6am 8im ;an '3r;a7ar4an p3n>8an 73'ai S>ra8

63

CONTOH FORMAT

P3rin8a= T>n;anC

;3nan

p3ra8>ran

p3r>n;an<-

K$$mpa+

: Apa'i6a ;ipan;an< p3r6> 8im p3r3nana 8im p36a47ana ;an 8im p3n8 83nam'3r"in78r>48>r"83na 436ompo4 ma7?ara4a8 ?an< ;ian<ai 43
K$'ima

: Ma7a 8>6an ;an a8a> ;in?a8a4an '3ra4=ir 73836a= p36a47anaan 43; 73637ai ;3n6> m3n?ampai4an 6aporan a4=irC

K$$nam

: S38>7an ini ;i'3'an4an pa;a An<an K3r5a  K"L"D"I Ta=>n An<
K$+*.*

: K3p>8>7an ini '3r6a4> 735a4 8an<an 'a=@a apa'i6a ;i43m>;ian =ari 83r;apa8 43436ir>an ;a6am p3n38apan ini a4an ;ia;a4an p3r'ai4an D3mi4ian a= 8an<<>n< 5a@a' DITETAPKAN DI: 99999999999 PADA TANGGAL: 99999999999 P35a'a8 P3m'>a8 Komi8m3n

999 999999999999 NIP 9999999999 TEM#USAN S>ra8 P3n>
KERANGKA A6UAN KER!A

Pa$+ P$$r.aan99999999999999  ( nama pa438 p343r5aan ) )

64

CONTOH FORMAT

Ta=>n An<
%a8a8an : ) ;ii7i o63= 8im p3r3nana

65

CONTOH FORMAT

A.

KERANGKA A6UAN KER!A (KAK)

1.

LATAR ELAKANG

 9999999999999999999999999)

2.

MAKSUD DAN TU!UAN

Ma47>; 9999999999999999999999999) T>5>an 999999999999999999999999 ) 1  ) 2  ) !  ) $ ;78)

3.

SASARAN

4.

NAMA DAN ORGANISASI PE!AAT PEMUAT KOMITMEN

  (;ii7i o63= 8im p3r3nana on8o= : P35a'a8 P3m'>a8 Komi8m3n K37>nan P3n?3mp>rnaan"P3n<54a5ian P3ra8>ran P3r>n;an<-Un;anan K3r5a #a;an P3n<3m'anm'3r Da?a Man>7ia)

5.

SUMER PENDANAAN

Un8>4 p36a47anaan 434an

'ia?a 4>ran< 63'i=

Rp 99999 ( 999999 ) 83rma7>4 PPN ;i'ia?ai AP#N Ta=>n An<
LINGKUP7 LOKASI KEGIATAN7 DATA DAN FASILITAS PENUN!ANG SERTA ALI2 PENGETA2UAN

a Lin<4>p K3p 437 ;i6a47ana4an ;i @i6a?a= N3an R3p>'6i4 In;on37ia

66

CONTOH FORMAT

 Da8a ;an &a7i6i8a7 P3n>n5an< (5i4a ;ip3r6>4an) 1) P3n?3;iaan o63= P35a'a8 P3m'>a8 Komi8m3n Da8a ;an fa7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n ?an< ;apa8 ;i<>na4an ;an =ar>7 ;ip36i=ara o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oranmp>6an 6aporan ;an ;a8a 73'a;i 83r;a=>6> 73r8a p=o8o p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73orananana8 Komi8m3n mi7a6n?a r>ana7">4>rann?a ;an 43a;aann?a a8a> =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73orana8 Komi8m3n ;apa8 m3n @a4i6n?a ?an< '3r8in;a4 73'a p3n;ampin< (o>n83rpar8) a8a> pro538 offi3r (PO) ;a6am ran<4a p36a47anaan 7@a436o6a) ;)&a7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n ?an< ;apa8 ;i<>na4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oranm4an nama ;an 5>m6a= 'aran< 83r73'>8)) 2) P3n?3;iaan o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran7 m3n?3;ia4an ;an m3m36i=ara 73m>a fa7i6i8a7 ;an p3ra6a8an ?an< ;ip3r<>na4an >n8>4 436anaran p36a47anaan p343r5aan (%an8>m4an nama ;an 5>m6a= 'aran<-'aran< ?an< =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran 7 ;i'36i a8a7 nama P35a'a8 P3m'>a8 Komi8m3n a8a> =ar>7 ;3nan Apa'i6a ;ipan;an< p3r6> o63= P35a'a8 P3m'>a8 Komi8m3n 

67

CONTOH FORMAT

ma4a 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran7 m3nr7>7 7in<4a8 ;i74>7i ;an 73minar 83r4ai8 ;3n'78an7i p36a47anaan p343r5aan ;a6am ran<4a a6i= p3n<38a=>an 43pa;a 78af ;i 6in<4>na8 Komi8m3n 7.

8. 9.

PENDEKATAN DAN a ) ' ) METODOLOGI ;78) " METODE PELAKSANAAN " SPESIFIKASI TEKNIS !ANGKA WAKTU an<4a @a48> p36a47anaan 436an PELAKSANAAN TENAGA A2LI P3n?3;ia 5a7a =ar>7 '3r8in;a4 73'a4an >n8>4 m36a47ana4an p343r5aan ini a;a6a= T3na 6>7an >ni3r7i8a7"p3r<>r>ran 8in< ?an< ;i7ama4an ?an< '3rp3n''i;an<) S34>ran<4>rann)

10.

KELUARAN

11.

LAPORAN

K36>aran ?an< ;i=a7i64an ;ari p36a47anaan p343r5aan ini a;a6a= ) 3ni7 6aporan ?an< =ar>7 ;i73ra=4an 43pa;a P35a'a8 P3m'>a8 Komi8m3n a;a6a=: a

Laporan #>6anan

'

Laporan R3a6i7a7i P343r5aan



Laporan P3na7i

;

Laporan K=>7>7 ('i6a ;ip3r6>4an)

Laporan '>6anan =ar>7 ;i73ra=4an 738iap a4=ir '>6an 735a4 SPMK ;i83r'i84an 73'an?a4 9 (9999)) '>4> 6aporan ;an %D '3ri7i 736>r>= 6aporan 83rma7>4 7>mmar? r3por8 9 (9) ) '>a=

PEA#AT PEM#UAT KOMITMEN

( 99999999999 ) NIP99999999

68

CONTOH FORMAT

Lampiran 53 : KERANGKA A6UAN KER!A PEKER!AAN LAINN8A(TEMPLATE SWAKELOLA - 53)

KERANGKA A6UAN KER!A

Pa$+ P$$r.aan99999999999999  ( nama pa438 p343r5aan ) )

Ta=>n An<
69

CONTOH FORMAT

%a8a8an : ) ;ii7i o63= 8im p3r3nana

70

CONTOH FORMAT

B.

KERANGKA A6UAN KER!A (KAK)

1.

LATAR ELAKANG

 9999999999999999999999999)

2.

MAKSUD DAN TU!UAN

Ma47>; 9999999999999999999999999) T>5>an 999999999999999999999999 ) 1 ) 2 ) ! ) $ ;78 )

3.

SASARAN

4.

NAMA DAN ORGANISASI PE!AAT PEMUAT KOMITMEN

  (;ii7i o63= 8im p3r3nana on8o= : P35a'a8 P3m'>a8 Komi8m3n 9999999999999999999999)

5.

SUMER PENDANAAN

Un8>4 p36a47anaan 434an

'ia?a 4>ran< 63'i=

Rp 99999 ( 999999 ) 83rma7>4 PPN ;i'ia?ai AP#N Ta=>n An<
LINGKUP7 LOKASI KEGIATAN7 DATA DAN FASILITAS PENUN!ANG SERTA ALI2 PENGETA2UAN

a Lin<4>p K3p 437 ;i6a47ana4an ;i @i6a?a= N3an R3p>'6i4 In;on37ia  Da8a ;an &a7i6i8a7 P3n>n5an< (5i4a ;ip3r6>4an) !) P3n?3;iaan o63= P35a'a8 P3m'>a8 Komi8m3n Da8a ;an fa7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8

71

CONTOH FORMAT

Komi8m3n ?an< ;apa8 ;i<>na4an ;an =ar>7 ;ip36i=ara o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oranmp>6an 6aporan ;an ;a8a 73'a;i 83r;a=>6> 73r8a p=o8o p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73orananana8 Komi8m3n mi7a6n?a r>ana7">4>rann?a ;an 43a;aann?a a8a> =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73orana8 Komi8m3n ;apa8 m3n @a4i6n?a ?an< '3r8in;a4 73'a p3n;ampin< (o>n83rpar8) a8a> pro538 offi3r (PO) ;a6am ran<4a p36a47anaan 7@a436o6a) ;)&a7i6i8a7 ?an< ;i73;ia4an o63= P35a'a8 P3m'>a8 Komi8m3n ?an< ;apa8 ;i<>na4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oranm4an nama ;an 5>m6a= 'aran< 83r73'>8)) $) P3n?3;iaan o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a"p3n?3;ia 5a7a p3r73oran p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran7 m3n?3;ia4an ;an m3m36i=ara 73m>a fa7i6i8a7 ;an p3ra6a8an ?an< ;ip3r<>na4an >n8>4 436anaran p36a47anaan p343r5aan (%an8>m4an nama ;an 5>m6a= 'aran<-'aran< ?an< =ar>7 ;i73;ia4an o63= 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran7 ;i'36i a8a7 nama P35a'a8 P3m'>a8 Komi8m3n a8a> =ar>7 ;3nan Apa'i6a ;ipan;an< p3r6> o63= P35a'a8 P3m'>a8 Komi8m3n  ma4a 8im 7@a436o6a a8a> p3n?3;ia 5a7a " p3n?3;ia 5a7a p3r73oran7 m3nr7>7 7in<4a8 ;i74>7i ;an 73minar 83r4ai8 ;3n'78an7i p36a47anaan p343r5aan ;a6am ran<4a a6i= p3n<38a=>an 43pa;a 78af ;i 6in<4>na8 Komi8m3n

72

CONTOH FORMAT

7.

8. 9.

PENDEKATAN DAN a ) ' ) METODOLOGI ;78) !ANGKA WAKTU an<4a @a48> p36a47anaan 436an PELAKSANAAN TENAGA A2LI P3n?3;ia 5a7a =ar>7 '3r8in;a4 73'a4an >n8>4 m36a47ana4an p343r5aan ini a;a6a= T3na 6>7an >ni3r7i8a7"p3r<>r>ran 8in< ?an< ;i7ama4an ?an< '3rp3n''i;an<) S34>ran<4>rann)

10.

KELUARAN

11.

LAPORAN

K36>aran ?an< ;i=a7i64an ;ari p36a47anaan p343r5aan ini a;a6a= ) 3ni7 6aporan ?an< =ar>7 ;i73ra=4an 43pa;a P35a'a8 P3m'>a8 Komi8m3n a;a6a=: a

Laporan #>6anan

'

Laporan R3a6i7a7i P343r5aan



Laporan P3na7i

;

Laporan K=>7>7 ('i6a ;ip3r6>4an)

Laporan '>6anan =ar>7 ;i73ra=4an 738iap a4=ir '>6an 735a4 SPMK ;i83r'i84an 73'an?a4 9 (9999)) '>4> 6aporan ;an %D '3ri7i 736>r>= 6aporan 83rma7>4 7>mmar? r3por8 9 (9) ) '>a=

PEA#AT PEM#UAT KOMITMEN

( 99999999999 ) NIP99999999

73

CONTOH FORMAT

Lampiran 9 : GAMAR REN6ANA DAN SPESIFIKASI TEKNIS PEKER!AAN (TEMPLATE SWAKELOLA - 9) &orma8 Gam'ar : A1"A!

PPK……………………………..

LOKASI

GAMBAR

DIGAMBAR

DIRENCANA

DIPERIKSA

DISETUJUi

(TAHUN)

74

CONTOH FORMAT

Lampiran  : !ADUAL PELAKSANAAN PEKER!AAN" KEGIATAN (TEMPLATE SWAKELOLA - )

M3n<38a=>i P3n
M3n?38>5>i P35a'a8 P3m'>a8 Komi8m3n

 NIP 99999999999

99999999999 999  NIP 9999999

75

CONTOH FORMAT

76

CONTOH FORMAT

Lampiran ; : !ADUAL PENGADAAN"KEUTU2AN A2AN7 TENAGA KER!A7 DAN PERALATAN (TEMPLATE SWAKELOLA - ;)

77

CONTOH FORMAT

K"L"D"I Sa8>an 43r5a"SNT

:  :  APR

MEI

!UN

P343r5aan Ta=>n An<
AUG

SEP

O6T

NO<

DE6

!AN

FE

:  :  MAR

KETERANGAN

1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ 1 2 ! $ E,I%LES"KENDARAAN 99999999999 99999999999 99999999999 EFUIPMENT"PERALATAN 99999999999 99999999999 99999999999 MATERIAL"#A,AN 99999999999 99999999999 TENAGA KERA"LA#OUR 99999999999 99999999999

78

Lampiran = : REN6ANA ANGGARAN IA8A (RA) (TEMPLATE SWAKELOLA - =) Sa8>an 43r5a P343r5aan Ta=>n An<
I

!ENIS PEKER!AAN

:  :  :  6ARA PERAIK AN

SATU AN

KUAN TITAS AWAL

KUAN TITAS R6N PEL#

2ARGA SATUAN

IA8A

SU TOTAL

Lampiran > : SK PENGANGKATAN PANITIA PENGADAAN (TEMPLATE SWAKELOLA - >) KOP SURAT

KEPUTUSAN KEPALA SATUAN KER!A KEGIATAN ################################################################## SATUAN KER!A ###################################################################### ####################################################################################################### DEPARTEMEN #################################### NOMOR : ################################### TENTANG PENGANGKATAN PANITIA PENGADAAN KEGIATAN SWAKELOLA KEGIATAN #################################################################### ############################################################################################# K"L"D"I################################### TA2UN ANGGARAN ######## M$nim3an%

: a

#a=@a ;a6am ran<4a p36a47anaan K3n An< ;an m3m3n>=i 7?ara8 >n8>4 ;i8>n5>4 ;an ;ian<4a8 73'aan K3r5a;i Lin<4>nn8>4 ma47>; 83r73'>8 ma4a p3r6> ;i838ap4an ;3n8>7an K3pa6a Sa8>an K3r5a999999999 999999999999999C

M$n%in%a+

: 1

P3ra8>ran Pr37i;3n R3p>'6i4 In;on37ia no $ Ta=>n 2010 83n8an< P3n8>7anC ! 99999999999999999999999999999999999 999C $ 999999999999999999999999999999999999;78 MEMUTUSKAN

M$n$+apan

:

K$,a+*

: M3m'3n8>4 Pani8ia P3nnan K3r5a ;3n7>nan 73'a8 :

No# 1  0 5

K$4*a

NAMA

NIP

!AATAN DALAM TIM K$+*a S$r$+ari, An%%o+a D,+

: T>n< 5a@a' Pani8ia P3n8 : 1 m3n?>7>n r3nana p3mi6i=an P3n?3;ia #aran<"a7aC 2 m3n38ap4an Do4>m3n P3nm>m4an p36a47anaan P3nm>man r37mi >n8>4 ma7?ara4a8 73r8a m3n?ampai4an 43 LPSE >n8>4 ;i>m>m4an ;a6am Por8a6 P3na6ifi4a7i P3n?3;ia #aran<"a7a m36a6>i pra4>a6ifi4a7i a8a> pa7a4>a6ifi4a7iC * m36a4>4an 3a6>a7i a;mini78ra7i 834ni7 ;an =ar4C + m3n5a@a' 7an<n8>4: i P3636an P3n>n5>4an Lan<7>n< >n8>4 pa438 P3n47i"a7a Lainn?a ?an< '3rni6ai pa6in< 8in<7 mi6iar r>pia=)C a8a> ii S36347i a8a> P3n>n5>4an Lan<7>n< >n8>4 pa438 P3n68an7i ?an< '3rni6ai pa6in< 8in<6>= mi6iar r>pia=)C / m3n?3ra=4an 7a6inan Do4>m3n P3mi6i=an P3n?3;ia #aran<"a7a 43pa;a PPKC 10 m3n?impan ;o4>m3n a76i p3mi6i=an P3n?3;ia #aran<"a7aC 11 m3m'>a8 6aporan m3n<3nai pro737 ;an =a7i6 P3n7iC ;an 12 m3m'3ri4an p3r8an<<>n<5a@a'an a8a7 p36a47anaan 437>64an 43pa;a PPK p3r>'a=an ,PSC ;an"a8a> p3r>'a=an 7p37ifi4a7i 834ni7 p343r5aan apa'i6a ;ian<

K$+i%a

: 1

Pani8ia P3nn< 5a@a' 43pa7a 43pa6a Sa8>an K3r5a ;an P35a'a8 ?an< m36a4>4an 8in;a4an ?an< m3naran an<ra8 43p>8>7an ini ;i436>ar4an ! T>ra8 p3r5an5ian 43r5a ;i8an;a8ana '36a= pi=a4

K$$mpa+

: K3pa;a pani8ia p3nm 737>ai 43;>;>4ann?a ;a6am 8im ;an '3r;a7ar4an p3n>8an 73'ai S>ra8 P3rin8a= T>an p3ra8>ran p3r>n;an<>n;an

K$'ima

: S38>7an ini ;i'3'an4an pa;a An<an K3r5a  K"L"D"I  Ta=>n An<
K$$nam

: K3p>8>7an ini '3r6a4> 735a4 8an<an 'a=@a apa'i6a ;i43m>;ian =ari 83r;apa8 43436ir>an ;a6am p3n38apan ini a4an ;ia;a4an p3r'ai4an DITETAPKAN DI PADA TANGGAL

: ########################### : &&&&&&&&##

K$pa'a Sa+*an K$r.a

99999999999999999 NIP 99999999 TEM#USAN S>ra8 P3n>
Lampiran 1?a : LAPORAN 2ASIL SUR
NAMA SATUAN KERJA ................... ............................................................................

6ATATAN KONDISI DAN 2ASIL PENGUKURAN PROPINSI TANGGAL SURAI SATKER"SATKER NT %UA%A LOKASI NO

:999999999 :999999999999 :999999999 :999999999999 :99999999999

STA

KATEGORI

(4m)

KERUSAKAN

KETERANGAN

PETUGAS

(9999999999999 ) NIP 99999999999

Lampiran 1?3 : LAPORAN 2ASIL SUR
NAMA SATUAN KERJA ............................... ...........................................................................

6ATATAN KONDISI DAN 2ASIL SUR
KEGIATAN

:999999999 :999999999999 :999999999 :999999999999 :99999999999 URAIAN KEGIATAN

KETERANGAN

PETUGAS

(9999999999999 ) NIP 99999999999

Lampiran 11 : SURAT PENGA!UAN KEUTU2AN A2AN"MATERIAL7 TENAGA KER!A7 DAN PERALATAN (TEMPLATE SWAKELOLA - 11) KOP SURAT

Nomor Lamira!

: :"

……….., ..……………………

K#a$a %&'.: P#!!a A!ara!*P#+aa& P#ma& Komi&m#! K#ia&a! ………………………………………………………… ………………………………………………………. $i ………………………… P#ri'a- :

Permohonan Pengajuan Kebutuhan Bahan/Material, Tenaga Kerja, an Peralatan

B#rama i!i $iamai/a! a'0a !&/ m#!$/! /#&'a! a/a! P#!a$aa!………………………. !&/ S K#ia&a! …………………………….. a$a K#ia&a! ………………………………………., a$a Ta'! A!ara! ……………., /ami mo'o! a!&a! /ira!1a /ami $aa& m#r#a-iai/a! #!a$aa! #aai #ri/& :

NO

NAMA

3

Ba'a!*Ma&#ria-

4

T#!aa K#r+a

5

P#ra-a&a!

SATUAN

2OLUME

KETERANGAN

D#mi/ia! a&a a!&a!!1a, /ami 6a/a! &#rima /ai'. Tim P#-a/a!a S0a/#-o-a K#ia&a!……………………………………. …………………………………..

……………………………………… . NIP……………………….

Lampiran 1a : KONTRAK" PER!AN!IAN PENGADAAN ARANG"A2AN (TEMPLATE SWAKELOLA - 1a) KOP SURAT

SURAT PER!AN!IAN >n8>4 m36a47ana4an Pa438 P343r5aan P3n4an '3r'3n8>4 43mi8raan"KSO ma4a 4a6ima8 p3m'>4aan"4ompari7i 73'a8: SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an6an  8a=>n  H8an<6an ;an 8a=>n ;ii7i ;3nr>f an8ara  Hnama P35a'a8 P3m'>a8 Komi8m3n 736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama 7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n ?an< '3r43;>;>4an ;i  Ha6ama8 P35a'a8 P3m'>a8 Komi8m3n '3r;a7ar4an S>ra8 K3p>8>7an  Hp35a'a8 ?an< m3nan;a8ana8 Komi8m3n (736an5>8n?a ;i73'>8  PPK B) ;an  Hnama @a4i6 P3n?3;ia  H5a'a8an @a4i6 P3n?3;ia ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama P3n?3;ia ?an< '3r43;>;>4an ;i  Ha6ama8 P3n?3;ia '3r;a7ar4an A48a No8ari7 No  HNo A48a no8ari7 8an<ar4an o63= No8ari7  Hnama No8ari7 p3n3r'i8 A48a (736an5>8n?a ;i73'>8  P$n@$4ia B) Hi4a P3n?3;ia '3r'3n8>4 43mi8raan"KSO ma4a 4a6ima8 p3m'>4aan"4ompari7i 73'a8: SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an6an  8a=>n  H8an<6an ;an 8a=>n ;ii7i ;3nr>f an8ara  Hnama P35a'a8 P3m'>a8 Komi8m3n 736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama 7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n ?an< '3r43;>;>4an ;i  Ha6ama8 P35a'a8 P3m'>a8 Komi8m3n '3r;a7ar4an S>ra8 K3p>8>7an  Hp35a'a8 ?an< m3nan;a8ana8 Komi8m3n (736an5>8n?a ;i73'>8  PPK B) ;an 43mi8raan"KSO ?an< '3ran<8: 1  Hnama P3n?3;ia 1C 2  Hnama P3n?3;ia 2C  ;78 ?an< ma7in<-ma7in< an<n< 5a@a' 73ara pri'a;i ;an 8an<<>n< r3n83n< a8a7 73m>a 43@a5i'an 83r=a;ap PPK '3r;a7ar4an Kon8ra4 ini ;an 836a= m3n>n5>4  Hnama an<n5>4 73'an8>4 '3r8in;a4 a8a7 nama K3mi8raan ?an< '3r43;>;>4an ;i  Ha6ama8 P3n?3;ia @a4i6 43mi8raan '3r;a7ar4an 7>ra8 P3r5an5ian 43mi8raan"KSO No  8an<8n?a ;i73'>8  P$n@$4ia B)

MENGINGAT A2WA: (a)

PPK 836a= m3min8a P3n?3;ia >n8>4 m3n?3;ia4an #aran< 73'am Kon8ra4 ?an< 83r6ampir ;a6am Kon8ra4 ini (736an5>8n?a ;i73'>8 P$$r.aan P$n%a4aan aran%B)C

(')

P3n?3;ia 73'am'3r ;a?a 834ni7 73r8a 836a= m3n?38>5>i >n8>4 m3n?3;ia4an #aran< 737>ai ;3nan ;a6am Kon8ra4 iniC

()

PPK ;an P3n?3;ia m3n?a8a4an m3mi6i4i 43@3nann8>4 m3nan;a8an
(;)

PPK ;an P3n?3;ia m3ni ;an m3n?a8a4an 'a=@a 73=>'>nn8>4 ;i;ampin8C !) 836a= m3m'aa ;an m3ma=ami 73ara p3n>= 4383n8>an Kon8ra4 iniC $) 836a= m3n;apa84an 4373mpa8an ?an< m3ma;ai >n8>4 m3m3ri47a ;an m3n<4onfirma7i4an 73m>a 4383n8>an ;a6am Kon8ra4 ini '373r8a 73m>a fa48a ;an 4on;i7i ?an< 83r4ai8

MAKA OLE, KARENA ITU PPK ;an P3n?3;ia ;3n5>i =a6-=a6 73'a8: 1 H>n8>4 4on8ra4 =aran a8a> 4on8ra4 nan ;an 6>mp 7>m ;i8>6i7 73'a8 : 8o8a6 =ar Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) ?an< ;ip3ro63= '3r;a7ar4an 4>an8i8a7 ;an =ar an p343r5aan 73'am ;a6am Daf8ar K>an8i8a7 ;an ,ar pia=)CB H>n8>4 4on8ra4 6>mp 7>m ;i8>6i7 73'a8: 8o8a6 =ar Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) a;a6a= 73'37ar Rp ( r>pia=)CB 2 !

p3ri78i6a=an ;an >n<4apan ;a6am S>ra8 P3r5an5ian ini m3mi6i4i ar8i ;an ma4na ?an< 7ama 73p3r8i ?an< 83ran8>m ;a6am 6ampiran S>ra8 P3r5an5ian iniC ;o4>m3n-;o4>m3n '3ri4>8 m3r>pa4an 7a8>-437a8>an ;an 'am S>ra8 P3r5an5ianC ' po4o4 p3r5an5ianC  7>ra8 p3na@aranC ; ;af8ar 4>an8i8a7 ;an =ar7>7 Kon8ra4C f 7?ara8-7?ara8 >m>m Kon8ra4C < 7p37ifi4a7i 4=>7>7C = 7p37ifi4a7i >m>mC i m3n 6ainn?a 73p3r8i: 5aminan-5aminan SPP# #A,P #APP

$

Do4>m3n Kon8ra4 ;i'>a8 >n8>4 7a6in< m3n536a74an 7a8> 7ama 6ain ;an 5i4a 83r5a;i p3r83n8anan ;a6am 7>a8> ;o4>m3n ;3nan ;a6am ;o4>m3n ?an< 6ain ma4a ?an< '3r6a4> a;a6a= 4383n8>an ;a6am ;o4>m3n ?an< 63'i= 8in<r>8an =i3rar4i pa;a an<4a ! ;i a8a7C



,a4 ;an 43@a5i'an 8im'a6-'a6i4 PPK ;an P3n?3;ia ;in?a8a4an ;a6am Kon8ra4 ?an< m36ip>8i 4=>7>7n?a:

*

a.

PPK m3mp>n?ai =a4 ;an 43@a5i'an >n8>4: 1) m3n4an o63= P3n?3;iaC !) m3m'3ri4an fa7i6i8a7 '3r>pa 7arana ;an pra7arana ?an< ;i'>8>=4an o63= P3n?3;ia >n8>4 436anaran p36a47anaan p343r5aan 737>ai 4383n8>an Kon8ra4C $) m3m'a?ar p343r5aan 737>ai ;3nm ;a6am Kon8ra4 ?an< 836a= ;i838ap4an 43pa;a P3n?3;iaC

b.

P3n?3;ia m3mp>n?ai =a4 ;an 43@a5i'an >n8>4: 1) m3n3rima p3m'a?aran >n8>4 p36a47anaan p343r5aan 737>ai ;3n4an ;a6am Kon8ra4C 2) m3min8a fa7i6i8a7-fa7i6i8a7 ;a6am '3n8>4 7arana ;an pra7arana ;ari PPK >n8>4 436anaran p36a47anaan p343r5aan 737>ai 4383n8>an Kon8ra4C !) m36apor4an p36a47anaan p343r5aan 73ara p3rio;i4 43pa;a PPK C $) m36a47ana4an ;an m3n?3637ai4an p343r5aan 737>ai ;3nra8 ;an p3n>= 8an<<>n< 5a@a' ;3n8an 43 a8a> ;ari 6apanp>n 73m3n8ara ?an< ;ip3r6>4an >n8>4 p36a47anaan p3n?3637aian ;an p3r'ai4an p343r5aan ?an< ;irini ;a6am Kon8ra4C *) m3m'3ri4an 4383ran4an >n8>4 p3m3ri47aan p36a47anaan ?an< ;i6a4>4an PPKC +) m3n?3ra=4an =a7i6 p343r5aan 737>ai ;3n4>p m3ma;ai >n8>4 m36in;>nn7a4an ;an an 43pa;a ma7?ara4a8 ma>p>n mi6i4n?a a4i'a8 43
Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<m"K=>7>7 Kon8ra4 ;3n6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'ar ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4

DENGAN DEMIKIAN PPK ;an P3n?3;ia 836a= '3r73pa4a8 >n8>4 m3nan;a8an8 ;i a8a7 ;an m36a47ana4an Kon8ra4 737>ai ;3nan p3ra8>ran p3r>n;an<>n;an'6i4 In;on37ia Un8>4 ;an a8a7 nama  PPK

Un8>4 ;an a8a7 nama P3n?3;ia" 43mi8raan (KSO) 

H8an;a 8ann8>4 P3n?3;ia ma4a r34a84an ma83rai Rp *000- )

H8an;a 8ann8>4 7a8>an 43r5a PPK ma4a r34a84an ma83rai Rp *000- )

Hnama 63n<4ap  H5a'a8an

Hnama 63n<4ap H5a'a8an

Lampiran 13 : KONTRAK"PER!AN!IAN TENAGA A2LI ORANG PERSEORANGAN (TEMPLATE SWAKELOLA - 13)

SURAT PER!AN!IAN >n8>4 m36a47ana4an Pa438 P343r5aan a7a Kon7>68an7i P3roran
SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an6an  8a=>n  an8ara  Hnama P35a'a8 P3m'>a8 Komi8m3n  736a4> P35a'a8 P3m'>a8 Komi8m3n ?an< '3r8in;a4 >n8>4 ;an a8a7 nama  Hnama pro?34"7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n  ?an< '3r43;>;>4an ;i  Ha6ama8 P35a'a8 P3m'>a8 Komi8m3n  '3r;a7ar4an S>ra8 K3p>8>7an  Hp35a'a8 ?an< m3nan;a8an8n?a ;i73'>8 PPK B) ;an  Hnama p3n?3;ia  73'an8>4 ;an a8a7 nama  Hnama p3n?3;ia  ?an< '3ra6ama8 ;i  Ha6ama8 P3n?3;ia a7a Kon7>68an7i  '3r;a7ar4an 4ar8> i;3n8i8a7 '3r>pa  HKTP"SIM"Pa7por"i;3n8i8a7 6ain ?an< ma7i= '3r6a4> No  Hnomor 4ar8> i;3n8i8a7 (736an5>8n?a ;i73'>8 P$n@$4iaB)

MENGINGAT #A,WA: (a)

PPK 836a= m3min8a p3n?3;ia >n8>4 m3n?3;ia4an a7a Kon7>68an7i 73'am Kon8ra4 ?an< 83r6ampir ;a6am Kon8ra4 iniC

(')

P3n?3;ia 73'am'3r ;a?a 834ni7 ;an 836a= m3n?38>5>i >n8>4 m3n?3;ia4an a7a Kon7>68an7i 737>ai ;3nan ;a6am Kon8ra4 iniC

()

PPK ;an p3n?3;ia m3n?a8a4an m3mi6i4i 43@3nann8>4 m3nan;a8ann?ai 43@3nann8>4 m3n
(;)

PPK ;an p3n?3;ia m3ni ;an m3n?a8a4an 'a=@a 73=>'>nn8>4 ;i;ampin8C !) 836a= m3m'aa ;an m3ma=ami 73ara p3n>= 4383n8>an Kon8ra4 iniC $) 836a= m3n;apa84an 4373mpa8an ?an< m3ma;ai >n8>4 m3m3ri47a ;an m3n<4onfirma7i4an 73m>a 4383n8>an ;a6am Kon8ra4 ini '373r8a 73m>a fa48a ;an 4on;i7i ?an< 83r4ai8

MAKA OLE, KARENA ITU PPK ;an P3n?3;ia ;3n5>i =a6-=a6 73'a8:

1

H>n8>4 Kon8ra4 ,aran a8a> Kon8ra4 Ga'>nan ;an L>mp7>m ;i8>6i7 73'a8 : To8a6 =ar Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) ?an< ;ip3ro63= '3r;a7ar4an rinian 'ia?a 7a8>an p343r5aan 73'am ;a6am #3ri8a Aara ,a7i6 K6arifi4a7i ;an N3pia=)CB H>n8>4 Kon8ra4 L>mp7>m ;i8>6i7 73'a8 : JTo8a6 =ar Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) 73'am ;a6am #3ri8a Aara ,a7i6 K6arifi4a7i ;an N3pia=)CB

2

P3ri78i6a=an ;an >n<4apan ;a6am S>ra8 P3r5an5ian ini m3mi6i4i ar8i ;an ma4na ?an< 7ama 73p3r8i ?an< 83ran8>m ;a6am 6ampiran S>ra8 P3r5an5ian iniC

!

Do4>m3n-;o4>m3n '3ri4>8 m3r>pa4an 7a8>-437a8>an ;an 'am S>ra8 P3r5an5ian (apa'i6a a;a)C ') Po4o4 P3r5an5ianC ) S>ra8 P3na@aran '3ri4>8 Da8a P3na@aran #ia?aC ;) S?ara8-S?ara8 K=>7>7 Kon8ra4C 3) S?ara8-S?ara8 Um>m Kon8ra4C f) K3ran<4a A>an K3r5aC <) Da8a T34ni7 736ain K3ran<4a A>an K3r5aC =) Do4>m3n-;o4>m3n 4363n<4apan 736347i ?ai8> S>ra8 aminan S>ra8 P3n>n5>4an P3n?3;ia #aran<"a7a ;an #3ri8a-#3ri8a Aara S36347i

$

Do4>m3n Kon8ra4 ;i'>a8 >n8>4 7a6in< m3n536a74an 7a8> 7ama 6ain ;an 5i4a 83r5a;i p3r83n8anan ;a6am 7>a8> ;o4>m3n ;3nan ;a6am ;o4>m3n ?an< 6ain ma4a ?an< '3r6a4> a;a6a= 4383n8>an ;a6am ;o4>m3n ?an< 63'i= 8in<r>8an =i3rar4i pa;a an<4a ! ;i a8a7



,a4 ;an 43@a5i'an 8im'a6-'a6i4 PPK ;an p3n?3;ia ;in?a8a4an ;a6am Kon8ra4 ?an< m36ip>8i 4=>7>7n?a : a) P3n?3;ia '3r43@a5i'an >n8>4 m36a47ana4an p343r5aan a7a Kon7>68an7i >n8>4 PPK 737>ai ;3nan Kon8ra4C ;an ') PPK '3r43@a5i'an >n8>4 m36a4>4an p3m'a?aran 43pa;a p3n?3;ia 737>ai ;3nan Kon8ra4 Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'ar ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4

*

DENGAN DEMIKIAN PPK ;an p3n?3;ia 836a= '3r73pa4a8 >n8>4 m3nan;a8an8 ;i a8a7 ;an m36a47ana4an Kon8ra4 737>ai ;3nan p3ra8>ran p3r>n;an<>n;an ;i R3p>'6i4 In;on37ia

Un8>4 ;an a8a7 nama PPK

Un8>4 ;an a8a7 nama P3n?3;ia





H8an;a 8ann8>4 P3n?3;ia a7a Kon7>68an7i ma4a r34a84an ma83rai Rp *000-)

H8an;a 8ann8>4 pro?34"7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n ma4a r34a84an ma83rai Rp *000-)



Lampiran 1 : KONTRAK KER!A ORANG PERSEORANGAN ORONGAN (FORM SW - 1) SURAT PER!AN!IAN Nomor:  ANTARA ###################################################################### (4ii,i nama P$.a3a+ P$m3*a+ Komi+m$n) DAN ####################################################################### (4ii,i nama oran% p$r,$oran%an 3oron%an) UNTUK MELAKSANAKAN LAANAN ASA  Da6am Ran<4a 

S>ra8 p3r5an5ian ini ;i'>a8 ;i  pa;a =ari  8an<6an 8a=>n  an8ara ##################################### 736a4> P35a'a8 an< M36a4>4an Tin;a4an an< M3naran An<a8 Komi8m3n) Pa;a Uni8 K38n?a ;i73'>8 PI2AK KESATU ;an ####################################### 736a4> Oran< P3r73oran8n?a ;i73'>8 PI2AK KEDUA 736an5>8n?a ;i73'>8 KONTRAK 83r8an<a #36a= Pi=a4 m3n?38>5>i 73m>a 4383n8>an ?an< 83ran8>m ;a6am pa7a6pa7a6 '3ri4>8: 1 TUGAS PI,AK KEDUA: a PI,AK KEDUA =ar>7 m36a47ana4an La?anan a7a 99999999 ;a6am Ran<4a 999999999 737>ai ;3nm6a= @a48>999999 ;an ;i6a47ana4an ;i9999 ' PI,AK KEDUA =ar>7 m36a47ana4an La?anan a7a 99999999 ;a6am Ran<4a 999999999 737>ai ;3nm6a= o6>m3 p343r5aan ?an< 83r;iri ;ari9999999 ,ari ;an 8an<6ain?a p343r5aan a;a6a=99997ampai ;3ni @a48> ?an< 836a= ;i83n8>4an ma4a PI,AK KESATU 8i;a4 '3r43@a5i'an >n8>4 m3m'3ri4an 43pa;a PI,AK KEDUA ' Da6am p36a47anaan p343r5aan PI,AK KEDUA 736a6> =ar>7 m36a4>4an 4oor;ina7i ;3nn< 5a@a' pa438 43
93

Uni8 K3'>n8an  PI,AK KEDUA @a5i' m36a47ana4an p343r5aan 73ara 3rma8 a4>ra8 ;an p3n>= 8an<<>n<5a@a' 737>ai ?an< ;irini ;a6am 4on8ra4 ; PI,AK KEDUA @a5i' m36a47ana4an 736>r>= p343r5aan 737>ai 4383n8>an 4on8ra4 7ampai ;i83rima ;3nn8>4 436anaran p36a47anaan p343r5aan ' PI,AK KESATU @a5i' m3m'a?ar 43pa;a '3r;a7ar4an =ar
PI,AK KEDUA a8a7 p36a47anaan p343r5aan

! P343r5aan 'oronra8 P3r5an5ian ini '3r6a4> ;an m3na #36a= Pi=a4 735a4 8an<ra8 P3rin8a= M>6ai K3r5a ;i83r'i84an 73836a= S>ra8 P3r5an5ian ;i8an;a8ana6i 5i4a ;i73pa4a8i 6ain o63= K3;>a #36a= Pi=a4 a6ama8 PI,AK KESATU ;an PI,AK KEDUA a;a6a=: a A6ama8 PI,AK KESATU Uni8 K3a #36a= Pi=a4 836a= 73pa4a8 >n8>4 m3nan;a8anra8 P3r5an5ian ini pa;a 8an<8 ;i a8a7 PI2AK KEDUA

#####################################################

PI2AK KESATU P35a'a8 P3m'>a8 Komi8m3n Uni8 K3
&&&&&&&&&&&&&&## NIP 9999999

94

Lampiran 10 : LAPORAN PENERIMAAN DAN PENGGUNAAN A2AN"MATERIAL7 TENAGA KER!A7 DAN PERALATAN (TEMPLATE SWAKELOLA - 10) KOP SURAT

LAPORAN PENERIMAAN DAN PENGGUNAAN A2AN"MATERIAL7 TENAGA KER!A7 DAN PERALATAN Dir348ora8 Sa8>an 43r5a P343r5aan Ta=>n An<
:  :  :  : 

I#TENAGA KER!A NO

1 2 $ * + . / 10

KEA,LIAN

P36a47ana T>4an< #37i T>4an< #a8> T>4an< 4a?> Op3ra8or P3m'an8> Op3ra8or P343r5a 99999

UMLA,

II# A2AN"MATERIAL Tan<
3ni7 #a=an" Ma83ria6

>m6a= ?an< ;i83rima

>m6a= ?an< ;i8o6a4

III# ALAT >m6a= ?an< ;ipa4ai

3ni7

>m6a=

P$nan%%*n% !a/a3

9or< 9or< 9or< 9or< 9or< 9or< 9or< 9or< 9or<

P3n
P36a47ana P343r5aan

(99999999999) NIP99999999

(99999999999) NIP99999999

95

Lampiran 15a : LAPORAN 2ARIAN (TEMPLATE SWAKELOLA - 15a)

LAPORAN 2ARIAN ,ari 43 ,ari"T<6 P343r5aan

: 999999999 : 999999999 : 999999999

ITENAGA KERA NO KEA,LIAN

1 2 $ * + . / 10

P36a47ana T>4an< #37i T>4an< #a8> T>4an< 4a?> Op3ra8or P3m'an8> Op3ra8or P343r5a 99999

 %UA%A

UMLA,

II# A2AN 3ni7 ?an< ;a8an<

>m6a= ?an< ;i83rima

>m6a= ?an< ;i8o6a4

III# ALAT >m6a= ?an< ;ipa4ai

Si7a

53ni7

>m6a=

IPEKERAAN ANG DIKERAKAN ,ARI INI

KET

3ni7 P343r5aan

9or< 9or< 9or< 9or< 9or< 9or< 9or< 9or<

I AM KERA

II AM KERA E&EKTI&

P3n
P36a47ana P343r5aan

(99999999999) NIP99999999

(99999999999) NIP99999999

96

Lampiran 153 : LAPORAN MINGGUAN (TEMPLATE SWAKELOLA - 153)

LAPORAN MINGGUAN K$ma.*an P$$r.aan

: &&&&&&&&&&&&

Min<<> 43 -

: 99999999999999

TARGET NO

URAIAN

1

2

OLUME

#O#OT

!

$

#O#OT SD MINGGU LALU 

,ASIL PELAKSANAAN DALAM MINGGU INI OLUME PROSENTASE #O#OT () () * + .

#O#OT SD MINGGU LALU /

P3n
P36a47ana P343r5aan

(9999999999999999) NIP999999999999

(9999999999999999) NIP999999999999

KETERANGAN 10

97

Lampiran 15 : LAPORAN ULANAN (TEMPLATE SWAKELOLA - 15)

LAPORAN ULANAN

I

PRESTASI &ISIK REN%ANA () REALISASI () DEIASI ()

MINGGU I

MINGGU II

MINGGU III

MINGGU I

TOTAL

II

TENAGA KERA REN%ANA () REALISASI () DEIASI ()

MINGGU I

MINGGU II

MINGGU III

MINGGU I

TOTAL

III

ALAT REN%ANA () REALISASI () DEIASI ()

MINGGU I

MINGGU II

MINGGU III

MINGGU I

TOTAL

I

KEUANGAN REN%ANA () REALISASI () DEIASI ()

MINGGU I

MINGGU II

MINGGU III

MINGGU I

TOTAL

REKOMENDASI :

98

Lampiran 19 : PEMA8ARAN (TEMPLATE SWAKELOLA - 19) KOP SURAT ERITA A6ARA PEMA8ARAN Nomor :  P343r5aan Lo4a7i P343r5aan Ta=>n An<
: : : :

   

Pa;a =ari ini 998an<6an 98a=>n 999 (9- 9 - 99) 4ami ?an< '3r8an;a 8anra8 K3p>8>7an M3n83ri P343r5aan Um>m No99 T<6 99999 209 A6ama8 :  an< 736an5>8n?a ;i73'>8 PI,AK PERTAMA 2 Nama :  a'a8an :  A6ama8 :  S36an5>8n?a ;i73'>8 73'an8>4 ;an a8a7 nama 999999 ?an< ;i;iri4an '3r;a7ar4an A483 No8ari7  99999999 No 99 T<6 99 992099 #3r;a7ar4an : 1 S>ra8 P3rin8a= K3r5a Nomor : 999999999999999999999 8an<a '36a= pi=a4 836a= 73pa4a8 m3m'>a8 #3ri8a Aara P3m'a?aran ;3nm6a= ,ar m6a= an< T36a= Di'a?ar4an  Rp99999999999  ! >m6a= an< #36>m Di'a?ar4an  Rp99999999999 $ >m6a= an< ;imin8a4an  Rp99999999999 Po8on8 ;i'3'an4an 43pa;a DIPA (Daf8ar I7ian P36a47anaan An<a 73pa4a8 a8a7 5>m6a= p3m'a?aran 83r73'>8 ;i a8a7 ;i'a?ar4an 43pa;a #an4 99999  NoR343nin< :99999999999999999999999 D3mi4ian #3ri8a Aara ini ;i'>a8 ran<4ap 9(999) >n8>4 ;apa8 ;ip3r<>na4an 73'a
PI,AK PERTAMA (nama9999999)

99

a'a8an999 Lampiran 1 : DAFTAR 2ADIR (TEMPLATE SWAKELOLA  1)

NIP9999999

KOP SURAT

DAFTAR 2ADIR Dir348ora8 Sa8>an 43r5a"SNT P343r5aan Ta=>n An<
NAMA

: : : :

    TUGAS

,ADIR

TIDAK ,ADIR

TANDA TANGAN

KETERANGAN

100

Lampiran 1;: UKTI PEMA8ARAN PENGADAAN A2AN (TEMPLATE SWAKELOLA -1;)

#UKTI PEM#AARAN) No :…………………………… Sudah Terima dari

:…………………………………………………………………………………

Banyaknya Uang

: Rp…………………………………………………………………………….. (ditulis dengan huruf………………………………………………………...)

Untuk Pembayaran

: ………………………………………………………………………………… (diisi enis dan !olume barang"

……………#……………$%.…

(nama……………….……." &abatan……………...

'" rangkap $ (dua"

101

Lampiran 1= : PAN!AR KER!A (TEMPLATE SWAKELOLA - 1=)

PANAR KERA No :…………………………… Sudah Terima dari

:…………………………………………………………………………………

Banyaknya Uang

: Rp…………………………………………………………………………….. (ditulis dengan huruf………………………………………………………...)

Untuk Pembayaran

: …………………………………………………………………………………

……………#……………$%.…

(nama……………….……." &abatan……………...

102

Lampiran 1>a : REALISASI PEKER!AAN FISIK (TEMPLATE SWAKELOLA - 1>a) KOP SURAT

REALISASI PEKER!AAN SWAKELOLA LOKASI ANGGARAN ENIS KEGIATAN NAMA PEKERAAN

I

P3n<36o6a P343r5aan : 1# # 0# 5#

II

: 999999999999999999999999999999999999 : DIPA TA KEPALA SATKER" KEPALA SATKER NT %a'an< Dina7  999999999999999999999999999999999999 : 999999999999999999999999999999999999 : 999999999999999999999999999999999999

P$nan%%*n%.a/a3 P$r$nana P$'a,ana P$n%a/a,

P3rinian P343r5aan : 1# Manfaa+ #
III

: :

R3a6i7a7i P36a47anaan : 1# M*'ai P$'a,anaan # S$'$,ai 0# !*m'a 2ari

I

: : : :

: : : &&&&&&& ari $r.a#

R3a6i7a7i T3na
103

P$ra'a+an Mi'i ,$n4iri : a# &&&&&& : &&&&## *ni+ B  Rp# &&&&&& C Rp# &&&&&&&& 3# &&&&&& : &&&&## *ni+ B  Rp# &&&&&& C Rp# &&&&&&&& !*m'a C Rp# &&&&&&&& II

R3a6i7a7i P3r5a6anan Dina7 ;an #ia?a : a# aan aar : &&&## 'i+$r B  Rp# &&&& 3# SPPD Lapan%an : Rp# &&&&##### !*m'a

C Rp# &&&&&&&& C Rp# &&&&&&&& C Rp# &&&&&&&&

R3a6i7a7i Lain-6ain ;an #ia?a : a# Fo+o Do*m$n+a,i : LS B Rp# &&&&&&&&&&C Rp# &&&&&&&& 3# &&&&&&&&&## B  Rp# &&&&&&&&& C Rp# &&&&&&&& !*m'a C Rp# &&&&&&&& R34api8>6a7i P3n<36>aran #ia?a : 1# Upa C # aan-3aan C 0# P$ra'a+an C 5# P$r.a'anan Dina,C 9# Lain-'ain C To+a' C

Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&#

TERILANG : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&## !aar+a7 &&&&&&&&&##??&&# M$n@$+*.*i : P$n%a/a,

P$nan%%*n%.a/a3 P$$r.aan S/a$'o'a7

(&&&&&&&&&&&&&&## ) NIP: ####################################

( &&&&&&&&&&&&&&## ) NIP:################################

M$n%$+a*i : P$.a3a+ P$m3*a+ Komi+m$n

( &&&&&&&&&&&&&&# ) NIP:&&&&&&&&&&##

104

Lampiran 1>3 : REALISASI PEKER!AAN PEKER!AAN LAINN8A(TEMPLATE SWAKELOLA 1>3) KOP SURAT

REALISASI PEKER!AAN SWAKELOLA LOKASI ANGGARAN ENIS KEGIATAN NAMA PEKERAAN

I

P3n<36o6a P343r5aan : 1# # 0# 5#

II

: 999999999999999999999999999999999999 : 999999999999999999999999999999999999 : 999999999999999999999999999999999999 : 999999999999999999999999999999999999

P$nan%%*n%.a/a3 P$r$nana P$'a,ana P$n%a/a,

P3rinian P343r5aan : 1# Manfaa+ #
III

: :

R3a6i7a7i P36a47anaan : 1# M*'ai P$'a,anaan # S$'$,ai 0# !*m'a 2ari

I

: : : :

R3a6i7a7i T3na
: : : &&&&&&& ari $r.a#

#ia?a : : &&& *'an : &&& *'an : &&& *'an : &&& *'an

B B B B

or%# or%# or%# or%#

B Rp# B Rp# B Rp# B Rp#

&&&&&&# C &&&&&&# C &&&&&&# C &&&&&&# C

!*m'a

Rp# &&&&&&&& Rp# &&&&&&&& Rp# &&&&&&&& Rp# &&&&&&&&

C Rp# &&&&&&&###

R3a6i7a7i #a=an ;an #ia?a : a# &&&&&&# : &&&&& *ni+ B  Rp# &&&&&## C Rp# &&&&&&&## 3# &&&&&&# : &&&&## *ni+ B  Rp# &&&&&## C Rp# &&&&&&&## !*m'a C Rp# &&##&&&&& R3a6i7a7i P3ra6a8an ;an #ia?a : P$ra'a+an 4ari '*ar"an+* : a# &&&&&& : &&&&## *ni+ B  Rp# &&&&&& C Rp# &&&&&&&& 3# &&&&&& : &&&&## *ni+ B  Rp# &&&&&& C Rp# &&&&&&&& !*m'a C Rp# &&&&&&&&

105

P$ra'a+an Mi'i ,$n4iri : a# &&&&&& : &&&&## *ni+ B  Rp# &&&&&& C Rp# &&&&&&&& 3# &&&&&& : &&&&## *ni+ B  Rp# &&&&&& C Rp# &&&&&&&& !*m'a C Rp# &&&&&&&& II

R3a6i7a7i P3r5a6anan Dina7 ;an #ia?a : a# aan aar : &&&## 'i+$r B  Rp# &&&& 3# SPPD Lapan%an : Rp# &&&&##### !*m'a

C Rp# &&&&&&&& C Rp# &&&&&&&& C Rp# &&&&&&&&

R3a6i7a7i Lain-6ain ;an #ia?a : a# Fo+o Do*m$n+a,i : LS B Rp# &&&&&&&&&&C Rp# &&&&&&&& 3# &&&&&&&&&## B  Rp# &&&&&&&&& C Rp# &&&&&&&& !*m'a C Rp# &&&&&&&& R34api8>6a7i P3n<36>aran #ia?a : 1# Upa C # aan-3aan C 0# P$ra'a+an C 5# P$r.a'anan Dina,C 9# Lain-'ain C To+a' C

Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&# Rp# &&&&&&&&&&&#

TERILANG : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&## !aar+a7 &&&&&&&&&##??&&# M$n@$+*.*i : P$n%a/a,

P$nan%%*n%.a/a3 P$$r.aan S/a$'o'a7

(&&&&&&&&&&&&&&## ) NIP: ####################################

( &&&&&&&&&&&&&&## ) NIP:################################

M$n%$+a*i : P$.a3a+ P$m3*a+ Komi+m$n

( &&&&&&&&&&&&&&# ) NIP:&&&&&&&&&&##

106

Lampiran ? : LAPORAN PEKER!AAN SELESAI (TEMPLATE SWAKELOLA - ?) KOP SURAT

Nomor Lampiran

: :

  20

K3pa;a 8=: (;ii7i nama a8a7an 6an<7>n< PPK)         ;i &&&&&&&&&##

P3ri=a6 P3ri=a6 : Laporan P343r5aan P343r5aan S3637ai S3637ai S3=>'>nn An<ai 737>ai ;3n7>6an p3n?3ra=an 736>r>= p343r5aan 83r73'>8 ;i'a@a= ini : 1 Nama K3m'3r #ia?a : * R3a6i7a7i An< Ta=>n n An<< An<r>= P343r5aan 4ami 7ampai4an a8a7 p3r=a8iann?a 4ami >ap4an 83rima 4a7i=

M$n%$+a*i 9999999999999999999

999999999999999 NIP : 999999999

P$.a3a+ P$m3*a+ Komi+m$n 9999999999999999999

&&&&&&&&&&&&&& NIP : 999999999

T3m'>7an K3pa;a K3pa;a 8=: 1 999999999999999999

107

2

Ar7ip

108

Lampiran Lampiran Laporan Laporan P$$r.aan S$'$,ai ( Lampiran 1)

Lampiran Laporan P$$r.aan S$'$,ai(Lampiran )

109

110

Lampiran 1 : ERITA A6ARA PEN8ERA2AN PEKER!AAN SELESAI (TEMPLATE SWAKELOLA - 1) KOP SURAT

ERITA A6ARA PEN8ERA2AN PEKER!AAN SWAKELOLA P343r5aan Lo4a7i P343r5aan Maam P343r5aan Nomor"Tan<ra8 P3n>
Nomor Tan<
: 99999999999999999999 : 99999999999999999999 : 99999999999999999999 : 99999999999999999999 : 99999999999999999999

: 99999999999999999999 : 99999999999999999999

Pa;a =ari ini9999999998an<6an99999999998a=>n999999 an< #3r8an;a 8an
: 9999999999999999999999999999 : Sa843r" Sa843r Non 3r8i4a6 T3r83n8>"K3pa6a %a'an< Dina79999999999 S36an5>8n?a ;i73'>8 PI,AK KESATU

N a m a a'a8an

: 9999999999999999999999999999 :9999(po7i7i"5a'a8an ) 99999999999 73'aa8 Komi8m3n ;ima47>; ?an< 736an5>8n?a ;i73'>8 PI,AK KEDUA

K3;>a '36a= pi=a4 '3r;a7ar4an #3ri8a Aara P3m3ri47aan P343r5aan S@a436o6a 73637ai 100 Nomor 9999999999998an<8 :

PI,AK KEDUA m3n?3ra=4an 43pa;a PI,AK KESATU ;an PI,AK KESATU m3n3rima ;3nai ;3nan ?an< '3r6a4> #3ri8a Aara ini ;i'>a8 >n8>4 ;i<>na4an 73p3r6>n?a

PI,AK KESATU

( 99999999999999 ) NIP 999999999999

PI,AK KEDUA

( 99999999999999 ) NIP 999999999999

111

112

Lampiran a : DAFTAR SIMAK PENGELOLA ANGGARAN FISIK (TEMPLATE SWAKELOLA a) KOP SURAT SATUAN KER!A PEKER!AAN SWAKELOLA PROPINSI TA2UN ANGGARAN

: & &&&&&&&&&&&&&&&&&&&&&&&&&&&&# : & &&& &&&& &&& &&& &&&& &&& &&& &&&& &# : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&# : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&#

DAFTAR SIMAK SWAKELOLA DENGAN INSTANSI PEMERINTA2 PENGELOLA ANGGARAN (Fi,i) 1.

P$m3$n+*an Tim"P$.a3a+ S/a$'o'a N O

PEMENU2AN PERS8ARATAN

URAIAN

SUDA2

ELUM

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

a# A4mini,+ra,i

&&&###

&&&###

3# T$ni,

&&&###

&&&###

# K$*an%an

&&&###

&&&###

a# M$mi'ii in+$%ri+a, mora'7 4i,ip'in 4an +an%%*n% .a/a3

&&&###

&&&###

&&&###

&&&###

3# M$maami ,$'*r* p$$r.aan

&&&###

&&&###

&&&##

&&&###

1#

a# P$n$+apan S/a$'o'a 4a'am DIPA

#

An%%o+a Tim"P$.a3a+ S/a$'o'a +$r4iri 4ari a# P$r$nanaan An%%o+a)

P$$r.aan

3# P$'a,anaan An%%o+a)

P$$r.aan

(K$+*a7

S$r$+ari,7

# P$n%a/a,an An%%o+a)

P$$r.aan

(K$+*a7

S$r$+ari,7

(K$+*a7

S$r$+ari,7

4# P$ni'ai Air An%%o+a) 0#

5#

S$r$+ari,7

T$r4iri 4ari *n,*r-*n,*r @an% m$maami

P$r,@ara+an

# M$maami 3$r,an%*+an 9#

P$$r.aan

(K$+*a7

A6UAN

S*3,+an,i

p$$r.aan

S*ra+ $p*+*,an p$m3$n+*an Tim"P$.a3a+ S/a$'o'a

@an%

&&&&& &&&&&#??&## K$+*a Tim P$n%a/a,

P$.a3a+ P$m3*a+ Komi+m$n

999999999999999

9999999999999999

999999999999999 NIP : 999999999

&&&&&&&&&&&&&& NIP : 999999999

113

Lampiran 3 : DAFTAR SIMAK PENGELOLA ANGGARAN !ASA LAINN8A (TEMPLATE SWAKELOLA - 3) KOP SURAT SATUAN KER!A PEKER!AAN SWAKELOLA PROPINSI TA2UN ANGGARAN

: & &&&&&&&&&&&&&&&&&&&&&&&&&&&& : & &&& &&&& &&& &&& &&&& &&& &&& &&&& & : &&&&&&&&&&&&&&&&&&&&&&&&&&&&& : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&

DAFTAR SIMAK SWAKELOLA DENGAN INSTANSI PEMERINTA2 PENGELOLA ANGGARAN (!a,a Lainn@a) 2.

P$m3$n+*an Tim"P$.a3a+ S/a$'o'a NO


URAIAN

SUDA2

ELUM

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

a# A4mini,+ra,i

&&&###

&&&###

3# T$ni,

&&&###

&&&###

# K$*an%an

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&###

&&&##

&&&###

1#

a# P$n$+apan S/a$'o'a 4a'am DIPA

#

An%%o+a Tim"P$.a3a+ S/a$'o'a +$r4iri 4ari

0#

5#

a# P$r$nanaan P$$r.aan An%%o+a)

(K$+*a7 S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan (K$+*a7

S$r$+ari,7


P$r,@ara+an a# M$mi'ii in+$%ri+a, +an%%*n% .a/a3

mora'7

4i,ip'in

4an

3# M$maami ,$'*r* p$$r.aan # M$maami S*3,+an,i 3$r,an%*+an 9#

A6UAN

p$$r.aan


@an%

&&&&& &&&&&#??&## K$+*a Tim P$n%a/a,


999999999999999

9999999999999999

999999999999999 NIP : 999999999

&&&&&&&&&&&&&& NIP : 999999999

114

Lampiran  : DAFTAR SIMAK INSTANSI LAIN NON SWADANA FISIK (TEMPLATE SWAKELOLA - ) KOP SURAT SATUAN KER!A PEKER!AAN SWAKELOLA PROPINSI TA2UN ANGGARAN

: & &&&&&&&&&&&&&&&&&&&&&&&&&&&& : & &&& &&&& &&& &&& &&&& &&& &&& &&&& & : &&&&&&&&&&&&&&&&&&&&&&&&&&&&& : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&

DAFTAR SIMAK SWAKELOLA DENGAN INSTANSI PEMERINTA2 LAIN NON SWADANA (Fi,i) 3.



URAIAN

SUDA2

ELUM

1#

P$n$+apan S/a$'o'a 4a'am DIPA

&&&###

&&&###

#

Na,a K$,$paa+an K$r.a,ama (M$moran4*m of Un4$r,+an4in% )

&&&###

&&&###

0#

Kon+ra"P$r.an.ian

&&&###

&&&###

5#

An%%o+a Tim"P$.a3a+ S/a$'o'a +$r4iri 4ari &&&###

&&&###

&&&###

&&&###

&&&###

&&&###

4# A4mini,+ra,i

&&&###

&&&###

$# T$ni,

&&&###

&&&###

f# K$*an%an

&&&###

&&&###

4# M$mi'ii in+$%ri+a, mora'7 4i,ip'in 4an +an%%*n% .a/a3

&&&###

&&&###

&&&###

&&&###

$# M$maami ,$'*r* p$$r.aan

&&&###

&&&###

&&&##

&&&###

a# P$r$nanaan P$$r.aan An%%o+a)

(K$+*a7 S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan (K$+*a7

S$r$+ari,7

A6UAN

4# P$ni'ai Air P$$r.aan (K$+*a7 S$r$+ari,7 An%%o+a) 9#

#


P$r,@ara+an

f# ;#

M$maami S*3,+an,i 3$r,an%*+an

p$$r.aan


@an%

&&&&& &&&&&#??&## K$+*a Tim P$n%a/a,


999999999999999

9999999999999999 &&&&&&&&&&&&&&

115

999999999999999 NIP : 999999999

NIP : 999999999

Lampiran 4 : DAFTAR SIMAK INSTANSI LAIN NON SWADANA !ASA LAINN8A (TEMPLATE SWAKELOLA - 4) KOP SURAT SATUAN KER!A PEKER!AAN SWAKELOLA PROPINSI TA2UN ANGGARAN

: & &&&&&&&&&&&&&&&&&&&&&&&&&&&& : & &&& &&&& &&& &&& &&&& &&& &&& &&&& & : &&&&&&&&&&&&&&&&&&&&&&&&&&&&& : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&

DAFTAR SIMAK SWAKELOLA DENGAN INSTANSI PEMERINTA2 LAIN NON SWADANA (!a,a Lainn@a) 4.



URAIAN

SUDA2

ELUM

1#


&&&###

&&&###

#

Na,a K$,$paa+an K$r.a,ama (M$moran4*m of Un4$r,+an4in% )

&&&###

&&&###

0#

Kon+ra"P$r.an.ian

&&&###

&&&###

5#


&&&###

&&&###

&&&###

&&&###

&&&###

a# A4mini,+ra,i

&&&###

&&&###

3# T$ni,

&&&###

&&&###

# K$*an%an

&&&###

&&&###


&&&###

&&&###

&&&###

&&&###


&&&###

&&&###

&&&##

&&&###

a# P$r$nanaan An%%o+a)

P$$r.aan


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7

(K$+*a7

S$r$+ari,7


#

P$$r.aan

S$r$+ari,7


P$r,@ara+an

# M$maami S*3,+an,i 3$r,an%*+an ;#

(K$+*a7

A6UAN

p$$r.aan


@an%

&&&&& &&&&&#??&## K$+*a Tim P$n%a/a,


999999999999999

9999999999999999

116

999999999999999 NIP : 999999999

&&&&&&&&&&&&&& NIP : 999999999

Lampiran $ : DAFTAR SIMAK KELOMPOK MAS8ARAKAT FISIK (TEMPLATE SWAKELOLA $)

KOP SURAT SATUAN KER!A PEKER!AAN SWAKELOLA PROPINSI TA2UN ANGGARAN

: & &&&&&&&&&&&&&&&&&&&&&&&&&&&& : & &&& &&&& &&& &&& &&&& &&& &&& &&&& & : &&&&&&&&&&&&&&&&&&&&&&&&&&&&& : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&

DAFTAR SIMAK SWAKELOLA DENGAN KELOMPOK MAS8ARAKAT################## (Fi,i) 5.



URAIAN

SUDA2

ELUM

1#


&&&###

&&&###

#

S*ra+ P$n*n.*an K*a,a

&&&###

&&&###

0#


&&&###

&&&###

&&&###

&&&###

&&&###

a# A4mini,+ra,i

&&&###

&&&###

3# T$ni,

&&&###

&&&###

# K$*an%an

&&&###

&&&###


&&&###

&&&###

&&&###

&&&###


&&&###

&&&###

&&&##

&&&###


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7

(K$+*a7

S$r$+ari,7


9#

P$$r.aan


P$r,@ara+an

# M$maami S*3,+an,i 3$r,an%*+an #

A6UAN

p$$r.aan


@an%

&&&&& &&&&&#??&## K$+*a Tim P$n%a/a,


999999999999999

9999999999999999

117

999999999999999 NIP : 999999999

&&&&&&&&&&&&&& NIP : 999999999

118

Lampiran f : DAFTAR SIMAK KELOMPOK MAS8ARAKAT !ASA LAINN8A (TEMPLATE SWAKELOLA - f) KOP SURAT SATUAN KER!A PEKER!AAN SWAKELOLA PROPINSI TA2UN ANGGARAN

: & &&&&&&&&&&&&&&&&&&&&&&&&&&&& : & &&& &&&& &&& &&& &&&& &&& &&& &&&& ## # : &&&&&&&&&&&&&&&&&&&&&&&&&&&&& : &&&&&&&&&&&&&&&&&&&&&&&&&&&&&

DAFTAR SIMAK SWAKELOLA DENGAN KELOMPOK MAS8ARAKAT######################### (!a,a Lainn@a)

6.



URAIAN

SUDA2

ELUM

1#


&&&###

&&&###

#

S*ra+ P$n*n.*an K*a,a

&&&###

&&&###

0#


&&&###

&&&###

&&&###

&&&###

&&&###

a# A4mini,+ra,i

&&&###

&&&###

3# T$ni,

&&&###

&&&###

# K$*an%an

&&&###

&&&###


&&&###

&&&###

&&&###

&&&###


&&&###

&&&###

&&&##

&&&###


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7


P$$r.aan

(K$+*a7

S$r$+ari,7

(K$+*a7

S$r$+ari,7


9#

P$$r.aan


P$r,@ara+an

# M$maami S*3,+an,i 3$r,an%*+an #

A6UAN

p$$r.aan


@an%

&&&&& &&&&&#??&## K$+*a Tim P$n%a/a,


999999999999999

9999999999999999

999999999999999 NIP : 999999999

&&&&&&&&&&&&&& NIP : 999999999

119

Lampiran 0 : SURAT TUGAS PEMERIKSAAN DAN E
SURAT PERINTA2 TUGAS Nomor : &&&&&&&&&&&#

P35a'a8 ?an< M36a4>4an Tin;a4an ?an< m3naran An<ni8 43r5a ) ;3n
:

99999999999999999999

a'a8an

:

999999999999999999999999999999999999

Pan<4a8"Go6on
:

99

Di8>
:

999999

Da6am Ran<4a

:

P3m3ri47aan ;an Ea6>a7i K3
S36ama

:

9

Tan<
:

99999999999999

Tan<
:

99999999999999

K3n;araan

:

99999999999

P3m'3'anan

:

K#ia&a! …………………………………………………………………… MAK : 999999999 ………………………………………..

(999) =ari

,arap 73<3ra ;i6a47ana4an ;an m36apor 73836a= 73637ai DIKELUARKAN DI PADA TANGGAL

: :

999999 9999999999999

P35a'a8 an< M36a4>4an Tin;a4an an< M3naran An<a8 Komi8m3n

99999999999999 NIP 999999999

120

Bagi_word_formulir_swakelola.doc

Recommend Documents