Contoh Laporan Lapora n Awal Awal
KOP LEMBAGA Nomor
:
......................................................
Lamp Lampir iran an :
.... ...... ..... ..... .... .... .... ..... ..... .... .... ..... ..... .... .... ..... ..... .... .... ..... ..... .... .... .... ..
Perihal
Laporan Awal DAK Non Fii!
:
.............., ................................2 017
Ban"#an BOP PA$D %ah#n An&&aran 2017
Kepa'a ("h. B#pa"i %e&al ).*. Kepala Dina Pen'i'i!an 'an Ke+#'aaan Ka+. %e&al 'i -lawi
Den&an horma",
-eh#+#n&an 'en&an Ban"#an Pen&a#an Propoal Ban"#an DAK Non Fii! BOP PA$D %ah#n 2017 pa'a lem+a&a %K/KB/PO- PA$D/%PA . "elah ma#! !e re!enin& !ami pa'a "an&&al Nomor 3e!enin& Ban! .. e+ear 3p. 4 , 'ana "ere+#" a!an !ami perna!an e#ai 3en)ana An&&aran Belana an& "er"era pa'a propoal a#an. -e+a&ai !elen&!apan !ami lampir!an : 1.
Fo"o Fo"o )op )op prin prin"" o#" +#!# +#!# re!e re!eni nin& n& +an! +an!
2.
Da5" Da5"ar ar pee peer" r"aa 'i'i 'i'i!/ !/m# m#ri ri' ' len&! len&!ap ap
6.
Da5"ar Pe Pen'i n'i'i!/N-%
.
8a'w 8a'wal al !e&i !e&ia" a"an an pem+ pem+el ela aar aran an
9.
3AB 3AB 43e 43en) n)an anaa An& An&&a &ara ran n Bela Belan na a
Demi Demi!i !ian an lapor laporan an pem+ pem+er eri" i"ah ah#a #an n awal awal !ami !ami amp ampai ai!a !an n #n"# #n"#! ! 'i!e 'i!e"a "ah# h#ii +a&i +a&i an& an& +er!epen"in&an. %erima %erima !aih.
-lawi , ................................ Men&e"ah#i Kapala -e!olah/Pen&elola
Ben'ahara
%K/KB/PO- PA$D/%PA .........
;on"oh -amp#l 4)o
NK
LAPORAN AWAL/ LAPORAN PERTAGGUNGJAWABAN (pilih salah satu) DANA BAN%$AN
Dia#!an Kepa'a B#pa"i %e&al ;*. Kepala Dina Pen'i'i!an 'an Ke+#'aaan Ka+#pa"en %e&al 'i -lawi
Dia#!an Oleh : %K/KB/%PA/Po PA$D/ :
Alama" Len&!ap Lem+a&a Pen#l ;on"a)" Peron / %elp.
Contoh Laporan Pertanggung Jawaban
KOP LEMBAGA Nomor
:
......................................................
Lampiran :
.......................................................
Perihal
Laporan Per"an&n& 8awa+an
:
.............., ................................2 017
Dana Ban"#an ?i+ah -#m+er Dana APBD Propini 8awa %en&ah %ah#n 2017
Kepa'a ("h. G#+ern#r 8awa %en&ah ).*. Kepala Dina Pen'i'i!an 'an Ke+#'aaan Propini 8awa %en&ah Di -lawi
Den&an horma",
-eh#+#n&an 'en&an Pen&a#an Permohonan Ban"#an Operaional Penelen&&araan 4BOP PA$D an& +er#m+er 'ari An&&aran Pen'apa"an 'an Belana Daerah Propini 8awa %en&ah %ah#n 2017 pa'a lem+a&a . "elah ma#! !e re!enin& !ami pa'a "an&&al Nomor 3e!enin& Ban! .. e+ear 3p. 4 , 'ana "ere+#" "elah !ami perna!an e#ai 3en)ana An&&aran Belana an& "er"era pa'a propoal a#an. -e+a&ai !elen&!apan !ami lampir!an : 1.
Fo"o )op prin" o#" +#!# re!enin& +an!
2.
Da5"ar peer"a 'i'i!/m#ri', pen&elola/penelen&&ara 'an pen'i'i!
6.
8a'wal !e&ia"an 'an 'o!#men lain an& rele
.
-"r#!"#r or&aniai lem+a&a PA$D
9.
3in)ian pen&naan 'ana +eer"a +#!"i+#!"i pen&el#aran/pem+elian
@.
Fo"o !e&ia"an, +ila mem#n&!in!an
Demi!ian laporan pem+eri"ah#an awal !ami ampai!an #n"#! 'i!e"ah#i +a&i an& +er!epen"in&an. %erima !aih.
-lawi , ................................ Men&e"ah#i Kapala -e!olah/Pen&elola
Ben'ahara
%K/KB/PO- PA$D/%PA .........
Contoh Kwitansi induk jika 1 toko
K=>%AN-> %elah "erima 'ari
: Kepala -e!olah/Pen&elola
$an& e#mlah
:
G#na mem+aar
: .......................................................................................................
%er+ilan&
:
3p. ..
................, ........................2017 (an& menerima Ma"erai 'an -"empel "o!o
............................................
-e"## 'i+aar oleh
L#na 'i+aar "an&&al .................
Kepala -e!olah/Pen&elola
Ben'ahara
..........................................
..............................................
...................................................
Contoh Kwitansi induk jika beberapa toko
K=>%AN-> %elah "erima 'ari
: Kepala -e!olah/Pen&elola
$an& e#mlah
:
G#na mem+aar
: .......................................................................................................
%er+ilan&
:
3p. ..
................,..................201@ (an& menerima
.............."erlampir..............................
-e"## 'i+aar oleh
L#na 'i+aar "an&&al .................
Kepala -e!olah/Pen&elola
Ben'ahara
..........................................
..............................................
...................................................
Contoh Kwitansi induk untuk Honor Guru/Transport
K=>%AN-> %elah "erima 'ari
: Kepala -e!olah/Pen&elola
$an& e#mlah
:
G#na mem+aar
: .......................................................................................................
%er+ilan&
:
3p. ..
................,..................201@ (an& menerima
.............."erlampir..............................
-e"## 'i+aar oleh
L#na 'i+aar "an&&al .................
Kepala -e!olah/Pen&elola
Ben'ahara
..........................................
..............................................
...................................................
;on"oh Penerimaan %ranpor"
DAF%A3 PENE3>MAAN %3AN-PO3%/?ONO3 ... B$LAN : ...........
No
Nama
$raian
Penerimaan
PPh 21 @
Penerimaan
%an'a
+erih
%an&an
%ranpor" G#r# .....
L#na 'i+aar ."&l . ...... Men&e"ah#i : Kepala -e!olah/Pen&elola ......
Ben'ahara,
.................................................
......................................
;on"oh Penerimaan %ranpor" !e&ia"an rapa"
DAF%A3 PENE3>MAAN %3AN-PO3% KEG>A%AN 3APA% B$LAN ................
No
Nama
$raian
Penerimaan
PPh 21 @
Penerimaan
%an'a
+erih
%an&an
%ranpor" !e&ia"an ......
L#na 'i+aar ."&l . ...... Men&e"ah#i : Kepala -e!olah/Pen&elola ......
Ben'ahara,
.................................................
......................................
Ke"eran&an : 1. Pem+elian har# 'i %o!o 'an 'ilampiri No"a 'ari %o!o. 2. Pem+elian Baran& "an&&al l#na 'i+aar e"elah Dana Ma#! Ke 3e!enin& 6. Kwi"ani in'#! Pem+elian 3p 290.000, .'. CCC.CCC 'i"empel ma"erai 6.000 Kwi"ani Pem+elian 'i a"a 3p. 1.000.000 'i"empel ma"erai @.000 . Apa+ila !wi"ani in'#! "er'iri 'ari +e+erapa pem+elian 'i "o!o 4"erlampir, No"a an& 'i+eri Ma"erai, apa+ila pem+elian hana a"# "o!o Ma"erai 'i"empel 'i Kwi"ani >n'#! 'an 'ilampiri no"a "o!o 9. %ranpor" G#r# 'an eenina apa+ila 'ila!ana!an e+el#m 'ana ma#!, 'i Kwi"ani 'i "#li L#na 'i+aarna +oleh e"elah "an&&al ma#! re!enin& @. $n"#! honor/"ranpor" r# !wi"ani penerima 'i "#li "erlampir 'an 'ilampiri 'a5"ar ha'ir 'an DAF%A3/+#!"i penerimaan 'an -K men&aar 7. $n"#! "ranpor" rapa" 'an eenina 'ilampiri #n'an&an 'an eenina. . ?onor/>nen"i5 'i!ena!an paa!, #n"#! %ranpor" "i'a! !ena paa! C. $n"#! Per"em#an 3apa"/Paren"in& Kwi"ani >n'#! 'ilampiri $n'an&an, Da5"ar ?a'ir, No"a Pem+elian
Ma!anan/-na)!,
No"#len. Apa+ila a'a nara#m+er 'ilampiri Permohonan
Nara#m+er, -#ra" %#&a mena'i Nara#m+er, Da5"ar Penerimaan %ranpor" Nara#m+er 'an 'a5"ar ?a'ir Nara#m+er, paa! -na)! 4Paa! -na)!/;a"erin& 2 10. ?ome ii" Kwi"ani 'ilampiri #ra" %#&a 'an Da5"ar Penerimaan Pe"#&a ?ome ii", +ila mela!#!an Pem+erian -e#a"# !epa'a an& 'i home
Lampiranlampiran 'il#ar -P8 4Form 01, 02, 0 'an 09
Form BOP01
FO3M$L>3 >->AN PE3N(A%AAN %ANGG$NG 8A=AB
(an& +er"an'a "an&an 'i +awah ini : Nama
:
8a+a"an
: Kepala/Pen&elola PA$D
Alama"
:
Den&an ini mena"a!an +ahwa : 1. Belana Ban"#an Operaional Penelen&&araan 4BOP PA$D "elah 'ina!an 'alam ran&!a men'#!#n& operaional PA$D 'an "i'a! #n"#! !eperl#an pri+a'i. 2.
Pen&naan Belana DAK Non Fii! BOP PA$D a'alah e+a&ai +eri!#" : Penerimaan Dana BOP PA$D Pen&naan Dana BOP PA$D
3p. ............................. :
a. Pro&ram Pem+elaaran
3p. .............................
+. Pro&ram Pen'#!#n&
3p. .............................
). Ke&ia"an Lainna
3p. .............................
4B#!"i pen&naan "erlampir
6. Apa+ila 'i!em#'ian hari perna"aan ini "i'a! e#ai 'en&an !ea'aan an& e+enarna, aa +ere'ia 'i!ena!an an!i a'mini"rai 'an/a"a# 'i"#n"#" &an"i r#&i 'an/a"a# "#n"#"an lainna e#ai 'en&an !e"en"#an pera"#ran per#n'an&#n'an&an an& +erla!#.
Demi!ian #ra" perna"aan ini 'i+#a" 'en&an e+enarna 'an +erma"erai )#!#p #n"#! 'iperna!an e+a&aimana me"ina
-lawi,............................2017 Kepala PA$D .........
Ma"erai
3p. @.000
.................................
FO3M BOP 02
3EN;ANA KEG>A%AN DAN ANGGA3AN -A%$AN 43KA- PA$D %A?$N ANGGA3AN 2017
Nama -a"#an
:
Dea/Kel#rahan
:
Ke)ama"an
:
Ka+#pa"en
:
Pro
:
-#m+er Dana
: DAK Non Fii! BOP PA$D
No
$raian Ke&ia"an
Biaa
=a!"#
Mene"##i
-lawi,................................... 2017
Pen&elola/Kepala -e!olah
Ben'ahara/Penan&n& 8awa+ Ke&ia"an
...........................................
..................................................
FO3M BOP 0
PEN;A%A%AN PENGG$NAAN DANA BOP PA$D %A?$N ANGGA3AN 2017
Nama -a"#an
:
Dea/Kel#rahan
:
Ke)ama"an
:
Ka+#pa"en
:
Pro
:
-#m+er Dana
: DAK Non Fii! BOP PA$D
No
8eni Pen&el#aran
%&l/Bln
8ml
No. B#!"i
Mene"##i
-lawi,................................... 2017
Pen&elola/Kepala -e!olah
Ben'ahara/Penan&n& 8awa+ Ke&ia"an
...........................................
..................................................
FO3M BOP 09
LAP3O3AN PENGG$NAAN DANA DAK NON F>->K BOP PA$D %A?$N ANGGA3AN ...............
Nama -a"#an
:
Dea/Kel#rahan
:
Ke)ama"an
:
Ka+#pa"en
:
Pro
:
-#m+er Dana
: DAK Non Fii! BOP PA$D
No 1.
8eni Pen&el#aran Pro&ram Pem+elaaran
8ml
No. B#!"i
a. ............... +. ............... 2.
). .............. '"... Pro&ram Pen'#!#n& a. ................. +. .................
6.
). ................. '". Ke&ia"an Lainna a. ................. +. ................. ). ............... 8#mlah
Mene"##i
-lawi,................................... 2017
Pen&elola/Kepala -e!olah
Ben'ahara/Penan&n& 8awa+ Ke&ia"an
...........................................
..................................................