33
LAMPIRAN PERA PERATU TUR RAN BADAN ADAN PENGA ENGAWA WAS S UMUM NOMOR ... ... TAHUN TAHUN 2018 TENTANG PENANGANAN TEMUAN DAN PELANGGARAN PEMILIHAN UMUM
A.
PEM PEMILIH ILIHAN AN
LAPORAN
FORM FORMAT AT NOM NOMOR OR PEN PENER ERIM IMAAN AAN LAP LAPOR ORAN AN PEL PELAN ANGG GGAR ARAN AN
No. (1) /(2)/(3)/(4)/(5)/()/(!) /(2)/(3)/(4)/(5)/()/(!) "#$#%&'&' (1) No*o% L&+o%&'/T#* L&+o%&'/T#*,&' ,&' (2) -#' L&+o%&' L&+o%&' &$&, $#*,&' $#*,&' &. LP LP U'$, U'$, L&+ L&+o% o%&' &' . TM TM U'$, U'$, T#* T#*,& ,&' ' (3) -#' P#*, &. PL U'$, U'$, P#*, P#*, A'o$& A'o$& DPR DPR DPD DPD 6&' 6&' DPRD DPRD . PP U'$, U'$, P#*, P#*, P%#6#' P%#6#' 6&' W& P%#6#' P%#6#' (4) "o6# P#'&7& P#'&7& P#*, P#*, &. RI RI U'$ U'$, , B&7 B&7& &, , RI RI . P%o P%o U'$, U'$, B&7& B&7&, , P%o' P%o' 9. "& "& U'$, U'$, P#'&7& P#'&7& P#*, P#*, "&,+& "&,+&$#' $#' 6. "o$& "o$& U'$, U'$, P#' P#'&7& &7& P#* P#*, , "o$& "o$& #. "#9. .(N&*& .(N&*& "#9&*&$& "#9&*&$&')::. ')::. U'$, P#'&7& P#'&7& P#*, P#*, "#9&*&$&' "#9&*&$&' ;. PPL. :..(N&*& :..(N&*& "#,%&< "#,%&<&'):: &'):: U'$, U'$, P#'&7& P#'&7& P#*, P#*, L&+&'&' L&+&'&' . PLN....... PLN....... (N&*& (N&*& N#&%&).. N#&%&)...... .... U'$, U'$, P&'7&, P&'7&, L,&% L,&% N##% N##% (5) "o6# "o6# W&=&< W&=&< &. U'$, W&=&< W&=&< R#+, R#+, I'6o'#& I'6o'#& "o6# "o6# $#%&*+% $#%&*+% . N&*& N#&%& N#&%& $#*+&$ $#*+&$ 7&=&< 7&=&< P&'7& P&'7&, , LN #%$,& #%$,& () "o6# B,&' P#'#%*&&' P#'#%*&&' L&+o%&'/T#*,&' L&+o%&'/T#*,&' &. I I ,'$, ,'$, -&', -&',&% &% . II II ,'$, ,'$, F#% F#%,&% ,&% 9. III III ,'$ ,'$, , M&%# M&%#$$ 6. I> I> ,'$ ,'$, , A+% A+% #. > > ,' ,'$, $, M# M# ;. >I ,' ,'$, -,' . >II >II ,'$ ,'$, , -, -, <. >III >III ,'$, ,'$, A,$, A,$, . I? I? ,'$, ,'$, S#+ S#+$# $#* *#% #% @. ? ,'$, O$o#% . ?I ?I ,'$, ,'$, No# No#* *#% #% . ?II ?II ,'$ ,'$, , D## D##* *#% #% (!) "o6# "o6# T&<,' T&<,' &. 201 201! ! ,'$, ,'$, T&<,' T&<,' 201! 201! . 2018 2018 ,'$, ,'$, T&<,' T&<,' 2018 2018 9. 201 201 ,'$ ,'$, , T&<, T&<,' ' 201 201
34
o'$o< (1) +#'o*o +#'o*o%&' %&' L&+o%& L&+o%&' ' =&' =&' 6$#% 6$#%*& *& o#< o#< PPL D#& D#& S,&%&* S,&%&*& & "#9&*&$ "#9&*&$&' &' B&$,%%&<*&' 6 "o$& "o$& B&'6& A9#< A9#< +&6& &&$ P#*<&' W&o$& 6&' W& W&o$& B&'6& A9#< 6 +&6& $&'& 25 D##*#% 201 No*o% 01/LP/PW/PPL. S,&%&*&/01.01/?II/201 (2) P#'o*o%&' P#'o*o%&' T#*,&' =&' 6$#*,&' 6$#*,&' o#< P&'7&, "o$& B&'6& A9#< P&6& P#*<&' G,#%',% 6&' W& G,#%',% A9#< 6 7&=&< "o$& B&'6& A9#< +&6& $&'& 02 -&',&% 201! No*o% 01/TM/PG/"o$/01.01/I/201! (3) P#'o*o%&' P#'o*o%&' L&+o%&' =&' 6$#*,&' 6$#*,&' o#< P&'7&, P&'7&, "o$& B&'6& A9#< P&6& P#*<&' G,#%',% 6&' W& G,#%',% A9#< 6 7&=&< "o$& B&'6& A9#< +&6& $&'& 03 -&',&% 201! No*o% 02/LP/PG/"o$/01.01/I/201! (4) P#'o*o%&' L&+o%&' =&' 6$#*,&' o#< P&'7& "#9&*&$&' &$,%%&<*&' &$,%%&<*&' 6 "o$& B&'6& A9#< +&6& &&$ P#*<&' G,#%',% 6&' W& G,#%',% A9#< 6 W=&< "o$& B&'6& A9#< +&6& $&'& 3 -&',&% 201! No*o% 01/LP/PG/&*. B&$,%%&<*&'/01.01/I/201! (5) P#'o*o%&' P#'o*o%&' L&+o%&' =&' 6$#*,&' 6$#*,&' o#< P#'&7& P#*, P#*, L,&% N##% 6 N#&%& T&7&' +&6& &&$ +#&&'&&' P#*, DPR DPD 6&' DPRD +&6& $&'& 20 -&',&% 2018 No*o% 01/LP/PL/PLN.T&7&'/T&7&'/I/2018
DAFTAR "ODE WILACAH
34
o'$o< (1) +#'o*o +#'o*o%&' %&' L&+o%& L&+o%&' ' =&' =&' 6$#% 6$#%*& *& o#< o#< PPL D#& D#& S,&%&* S,&%&*& & "#9&*&$ "#9&*&$&' &' B&$,%%&<*&' 6 "o$& "o$& B&'6& A9#< A9#< +&6& &&$ P#*<&' W&o$& 6&' W& W&o$& B&'6& A9#< 6 +&6& $&'& 25 D##*#% 201 No*o% 01/LP/PW/PPL. S,&%&*&/01.01/?II/201 (2) P#'o*o%&' P#'o*o%&' T#*,&' =&' 6$#*,&' 6$#*,&' o#< P&'7&, "o$& B&'6& A9#< P&6& P#*<&' G,#%',% 6&' W& G,#%',% A9#< 6 7&=&< "o$& B&'6& A9#< +&6& $&'& 02 -&',&% 201! No*o% 01/TM/PG/"o$/01.01/I/201! (3) P#'o*o%&' P#'o*o%&' L&+o%&' =&' 6$#*,&' 6$#*,&' o#< P&'7&, P&'7&, "o$& B&'6& A9#< P&6& P#*<&' G,#%',% 6&' W& G,#%',% A9#< 6 7&=&< "o$& B&'6& A9#< +&6& $&'& 03 -&',&% 201! No*o% 02/LP/PG/"o$/01.01/I/201! (4) P#'o*o%&' L&+o%&' =&' 6$#*,&' o#< P&'7& "#9&*&$&' &$,%%&<*&' &$,%%&<*&' 6 "o$& B&'6& A9#< +&6& &&$ P#*<&' G,#%',% 6&' W& G,#%',% A9#< 6 W=&< "o$& B&'6& A9#< +&6& $&'& 3 -&',&% 201! No*o% 01/LP/PG/&*. B&$,%%&<*&'/01.01/I/201! (5) P#'o*o%&' P#'o*o%&' L&+o%&' =&' 6$#*,&' 6$#*,&' o#< P#'&7& P#*, P#*, L,&% N##% 6 N#&%& T&7&' +&6& &&$ +#&&'&&' P#*, DPR DPD 6&' DPRD +&6& $&'& 20 -&',&% 2018 No*o% 01/LP/PL/PLN.T&7&'/T&7&'/I/2018
DAFTAR "ODE WILACAH
35
PRO>INSI "ABUPATEN/"OTA DI INDONESIA No. 1. 2. 3. 4. 5. . !. 8. . 10. 11. 12. 13. 14. 15. 1. 1!. 18. 1. 20. 21. 22. 23. 24. 25. 2. 2!. 28. 2. 30. 31. 32. 33. 34. 35. 3. 3!. 38. 3. 40. 41. 42. 43. 44. 45. 4. 4!. 48. 4.
"ODE WILACAH 01.00 01.01 01.02 01.03 01.04 01.05 01.0 01.0! 01.08 01.0 01.10 01.11 01.12 01.13 01.14 01.15 01.1 01.1! 01.18 01.1 01.20 01.21 01.22 01.23 02.00 02.01 02.02 02.03 02.04 02.05 02.0 02.0! 02.08 02.0 02.10 02.11 02.12 02.13 02.14 02.15 02.1 02.1! 02.18 02.1 02.20 02.21 02.22 02.23 02.24
PRO>INSI
"&,+&$#'/"o$&
P%o' A9#< "o$& B&'6& A9#< "o$& S,,,&&* "o$& L&'& "o$& L
3
50. 51. 52. 53. 54. 55. 5. 5!. 58. 5. 0. 1. 2. 3. 4. 5. . !. 8. . !0. !1. !2. !3. !4. !5. !. !!. !8. !. 80. 81. 82. 83. 84. 85. 8. 8!. 88. 8. 0. 1. 2. 3. 4. 5. . !. 8. . 100. 101. 102.
02.25 02.2 02.2! 02.28 02.2 02.30 02.31 02.32 02.33 03.00 03.01 03.02 03.03 03.04 03.05 03.0 03.0! 03.08 03.0 03.10 03.11 03.12 03.13 03.14 03.15 03.1 03.1! 03.18 03.1 04.00 04.01 04.02 04.03 04.04 04.05 04.0 04.0! 04.08 04.0 04.10 04.11 04.12 05.00 05.01 05.02 05.03 05.04 05.05 05.0 05.0! 05.08 05.0 05.10
"&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#'
T&+&', T#'&< T&+&', U$&%& To& S&*o% P&6&' L&7& U$&%& P&6&' L&7& L&,<&'&$, U$&%& L&,<&'&$, S#&$&' N& B&%&$ N& U$&%&
S,*&$#%& B&%&$ "o$& P&6&' "o$& B,$$' "o$& P&6&' P&'@&' "o$& P&%&*&' "o$& P&=&,*,< "o$& S&7&<,'$o "o$& Soo "&,+&$#' A&* "&,+&$#' D<&%*&%&=& "&,+&$#' L*&+,,<o$& "&,+&$#' "#+,&,&' M#'$&7& "&,+&$#' P&6&' P&%&*&' "&,+&$#' P&&*&' "&,+&$#' P&&*&' B&%&$ "&,+&$#' P#% S#&$&' "&,+&$#' S&7&<,'$o S@,'@,' "&,+&$#' Soo "&,+&$#' Soo S#&$&' "&,+&$#' T&'&< D&$&% P%o' R&, "o$& P#&'&%, "o$& D,*& "&,+&$#' B#'& "&,+&$#' I'6%&% H% "&,+&$#' I'6%&% H,, "&,+&$#' "&*+&% "&,+&$#' ",&'$&' S'' "&,+&$#' P#&&7&' "&,+&$#' Ro&' H,, "&,+&$#' Ro&' H% "&,+&$#' S& "&,+&$#' "#+,&,&' M#%&'$ -&* "o$& -&* "o$& S,'& P#',< "&,+&$#' B&$&'<&% "&,+&$#' B,'o "&,+&$#' "#%'9 "&,+&$#' M#%&'' "&,+&$#' M,&%o -&* "&,+&$#' S&%o&',' "&,+&$#' T&'@,' -&,' B&%&$ "&,+&$#' T&'@,' -&,' T*,%
3!
103. 104. 105. 10. 10!. 108. 10. 110. 111. 112. 113. 114. 115. 11. 11!. 118. 11. 120. 121. 122. 123. 124. 125. 12. 12!. 128. 12. 130. 131. 132. 133. 134. 135. 13. 13!. 138. 13. 140. 141. 142. 143. 144. 145. 14. 14!. 148. 14. 150. 151. 152. 153. 154. 155.
05.11 0.00 0.01 0.02 0.03 0.04 0.05 0.0 0.0! 0.08 0.0 0.10 0.11 0.12 0.13 0.14 0.15 0.1 0.1! 0!.00 0!.01 0!.02 0!.03 0!.04 0!.05 0!.0 0!.0! 0!.08 0!.0 0!.10 08.00 08.01 08.02 08.03 08.04 08.05 08.0 08.0! 08.08 08.0 08.10 08.11 08.12 08.13 08.14 08.15 0.00 0.01 0.02 0.03 0.04 0.05 0.0
"&,+&$#' T#o S,*&$#%& S#&$&' "o$& P&#*&' "o$& L,, L'&, "o$& P&&% A&* "o$& P%&,*,< "&,+&$#' B&'=,&' "&,+&$#' L&<&$ "&,+&$#' E*+&$ L&7&' "&,+&$#' M,&%& E'* "&,+&$#' M, B&'=,&' "&,+&$#' M, R&7& "&,+&$#' O&' I% "&,+&$#' O&' "o*#%' I% "&,+&$#' O&' "#*#%' U, "&,+&$#' O"U S#&$&' "&,+&$#' O"U T*,% "&,+&$#' P#',& A& "&,+&$#' M, R&7& U$&%& B#',, "o$& B#',, "o$& B#',, S#&$&' "o$& B#',, U$&%& "&,+&$#' "&,% "&,+&$#' "#+&<&' "&,+&$#' L#o' "&,+&$#' M,o M,o "&,+&$#' R#@&' L#o' "&,+&$#' S#,*& "&,+&$#' B#',, T#'&< L&*+,' "o$& B&'6&%&*+,' "o$& M#$%o "&,+&$#' L&*+,' B&%&$ "&,+&$#' L&*+,' S#&$&' "&,+&$#' L&*+,' T#'&< "&,+&$#' L&*+,' T*,% "&,+&$#' L&*+,' U$&%& "&,+&$#' T&'&*, "&,+&$#' T,&' B&7&' "&,+&$#' W&= "&'&' "&,+&$#' P#&7&%&' "&,+&$#' P%'#7, "&,+&$#' M#,@ "&,+&$#' T,&' B&7&' B&%&$ "&,+&$#' P#% B&%&$ B&'& B#$,' "o$& P&'&+'&' "&,+&$#' B&'& "&,+&$#' B&'& B&%&$ "&,+&$#' B&'& S#&$&' "&,+&$#' B&'& T#'&< "&,+&$#' B#$,'
38
15. 15!. 158. 15. 10. 11. 12. 13. 14. 15. 1. 1!. 18. 1. 1!0. 1!1. 1!2. 1!3. 1!4. 1!5. 1!. 1!!. 1!8. 1!. 180.
0.0! 10.00 10.01 10.02 10.03 10.04 10.05 10.0 10.0! 11.00 11.01 11.02 11.03 11.04 11.05 11.0 11.0! 11.08 12.00 12.01 12.02 12.03 12.04 12.05 12.0
181. 182. 183. 184. 185. 18. 18!. 188. 18. 10. 11. 12. 13. 14. 15. 1. 1!. 18. 1. 200. 201. 202. 203. 204. 205. 20. 20!.
13.00 13.01 13.02 13.03 13.04 13.05 13.0 13.0! 13.08 13.0 13.10 13.11 13.12 13.13 13.14 13.15 13.1 13.1! 13.18 13.1 13.20 13.21 13.22 13.23 13.24 13.25 13.2
"&,+&$#' B#$,' T*,% "#+,&,&' R&, "o$& T&'@,' +'&' "o$& B&$&* "&,+&$#' "&%*,' "&,+&$#' B'$&' "&,+&$#' L'& "&,+&$#' N&$,'& "&,+&$#' "#+,&,&' A'&*& B&'$#' "o$& S#%&' "o$& T&'#%&' "o$& T&'#%&' S#&$&' "o$& #o' "&,+&$#' L#& "&,+&$#' P&'6#&' "&,+&$#' S#%&' "&,+&$#' T&'#%&' D"I -&&%$& "o$& A6*'$%& -&&%$& P,&$ "o$& A6*'$%& -&&%$& B&%&$ "o$& A6*'$%& -&&%$& S#&$&' "o$& A6*'$%& -&&%$& T*,% "o$& A6*'$%& -&&%$& U$&%& "&,+&$#' A6*'$%& "#+,&,&' S#%, -&7& B&%&$ "o$& B&'6,' "o$& B&'@&% "o$& B#& "o$& Boo% "o$& *&< "o$& %#o' "o$& D#+o "o$& S,&,* "o$& T&*&&=& "&,+&$#' B&'6,' "&,+&$#' B&'6,' B&%&$ "&,+&$#' B#& "&,+&$# Boo% "&,+&$#' &* "&,+&$#' &'@,% "&,+&$#' %#o' "&,+&$#' G&%,$ "&,+&$#' I'6%&*&=, "&,+&$#' "&%&7&' "&,+&$#' ",''&' "&,+&$#' M&@&#'& "&,+&$#' P,%7&&%$& "&,+&$#' S,&' "&,+&$#' S,&,* "&,+&$#' S,*#6&' "&,+&$#' T&*&&=&
3
208. 20. 210. 211. 212. 213. 214. 215. 21. 21!. 218. 21. 220. 221. 222. 223. 224. 225. 22. 22!. 228. 22. 230. 231. 232. 233. 234. 235. 23. 23!. 238. 23. 240. 241. 242. 243. 244. 245. 24. 24!. 248. 24.
250. 251. 252. 253. 254. 255. 25. 25!. 258. 25. 20.
13.2! 14.00 14.01 14.02 14.03 14.04 14.05 14.0 14.0! 14.08 14.0 14.10 14.11 14.12 14.13 14.14 14.15 14.1 14.1! 14.18 14.1 14.20 14.21 14.22 14.23 14.24 14.25 14.2 14.2! 14.28 14.2 14.30 14.31 14.32 14.33 14.34 14.35 15.00 15.01 15.02 15.03 15.04 15.05 1.00 1.01 1.02 1.03 1.04 1.05 1.0 1.0! 1.08 1.0
"&,+&$#' P&'&'6&%&' -&7& T#'&< "o$& S#*&%&' "o$& *&#&' "o$& P#&o'&' "o$& S&&$& "o$& S,%&&%$& "o$& T#& "&,+&$#' B&'@&%'#&%& "&,+&$#' B&'=,*& "&,+&$#' B&$&' "&,+&$#' Bo%& "&,+&$#' Bo=o& "&,+&$#' B%## "&,+&$#' &9&+ "&,+&$#' D#*& "&,+&$#' G%oo&' "&,+&$#' -#+&%& "&,+&$#' "&%&'&'=&% "&,+&$#' "#,*#' "&,+&$#' "#'6& "&,+&$#' "&$#' "&,+&$#' ",6, "&,+&$#' M&#&' "&,+&$#' P&$ "&,+&$#' P#&o'&' "&,+&$#' P#*&&' "&,+&$#' P,%&'& "&,+&$#' P,%7o%#@o "&,+&$#' R#*&' "&,+&$#' S#*&%&' "&,+&$#' S%&#' "&,+&$#' S,o<&%@o "&,+&$#' T#& "&,+&$#' T#*&',' "&,+&$#' Wo'o% "&,+&$#' Wo'ooo DI Co=&&%$& "o$& Co=&&%$& "&,+&$#' B&'$, "&,+&$#' G,',' "6, "&,+&$#' ",o' P%oo "&,+&$#' S#*&' -&7& T*,% "o$& "o$& "o$& "o$& "o$& "o$& "o$& "o$& "o$&
S,%&&=& B&$, B$&% "#6% M&6,' M&&' Mo@o#%$o P&,%,&' P%oo'o
40
21. 22. 23. 24. 25. 2. 2!. 28. 2. 2!0. 2!1. 2!2. 2!3. 2!4. 2!5. 2!. 2!!. 2!8. 2!. 280. 281. 282. 283. 284. 285. 28. 28!. 288. 28. 20. 21. 22. 23. 24. 25. 2. 2!. 28. 2.
1.10 1.11 1.12 1.13 1.14 1.15 1.1 1.1! 1.18 1.1 1.20 1.21 1.22 1.23 1.24 1.25 1.2 1.2! 1.28 1.2 1.30 1.31 1.32 1.33 1.34 1.35 1.3 1.3! 1.38 1!.00 1!.01 1!.02 1!.03 1!.04 1!.05 1!.0 1!.0! 1!.08 18.00
300. 301. 302. 303. 304. 305. 30. 30!. 308. 30. 310.
18.01 18.02 18.03 18.04 18.05 18.0 18.0! 18.08 18.0 18.10 1.00
311.
1.01
B&
"&,+&$#' B&'&&' "&,+&$#' B&'=,7&' "&,+&$#' B$&% "&,+&$#' Bo@o'#o%o "&,+&$#' Bo'6o7oo "&,+&$#' G%# "&,+&$#' -#*#% "&,+&$#' -o*&' "&,+&$#' "#6% "&,+&$#' L&*o'&' "&,+&$#' L,*&@&' "&,+&$#' M&6,' "&,+&$#' M&#$&' "&,+&$#' M&&' "&,+&$#' Mo@o#%$o "&,+&$#' N&'@, "&,+&$#' N&7 "&,+&$#' P&9$&' "&,+&$#' P&*#&&' "&,+&$#' P&,%,&' "&,+&$#' Po'o%oo "&,+&$#' P%oo'o "&,+&$#' S&*+&' "&,+&$#' S6o&%@o "&,+&$#' S$,o'6o "&,+&$#' S,*#'#+ "&,+&$#' T%#'&# "&,+&$#' T,,'&,' "&,+&$#' T,&' "o$& D#'+&&% "&,+&$#' B&6,' "&,+&$#' B&' "&,+&$#' B,##' "&,+&$#' G&'=&% "&,+&$#' -#*%&'& "&,+&$#' "&%&' A#* "&,+&$#' ",',' "&,+&$#' T&&'&'
N,& T#'&%& B&%&$ "o$& M&$&%&* "o$& B*& "&,+&$#' B*& "&,+&$#' Do*+, "&,+&$#' Lo*o B&%&$ "&,+&$#' Lo*o T#'&< "&,+&$#' Lo*o T*,% "&,+&$#' S,*&7& "&,+&$#' S,*&7& B&%&$ "&,+&$#' Lo*o U$&%& N,& T#'&%& T*,% "o$& ",+&'
41
312. 313. 314. 315. 31. 31!. 318. 31. 320. 321. 322. 323. 324. 325. 32. 32!. 328. 32. 330. 331. 332. 333. 334. 335. 33. 33!. 338. 33. 340. 341. 342. 343. 344. 345. 34. 34!. 348.
1.02 1.03 1.04 1.05 1.0 1.0! 1.08 1.0 1.10 1.11 1.12 1.13 1.14 1.15 1.1 1.1! 1.18 1.1 1.20 1.21 1.22 20.00 20.01 20.02 20.03 20.04 20.05 20.0 20.0! 20.08 20.0 20.10 20.11 20.12 20.13 20.14 21.00
34. 350. 351. 352. 353. 354. 355. 35. 35!. 358. 35. 30. 31. 32. 33.
21.01 21.02 21.03 21.04 21.05 21.0 21.0! 21.08 21.0 21.10 21.11 21.12 21.13 21.14 22.00
"&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#'
Ao% B#, E'6# Fo%# T*,% ",+&' L#*&$& M&'&%& M&'&%& B&%&$ N&6& N&##o Ro$# N6&o S& S,*& B&%&$ S,*& B&%&$ D&=& S,*& T#'&< M&'&%& TI*,% S,*& T*,% T*o% T#'&< S#&$&' T*o% T#'&< U$&%& S&, R&@,& M&&&
"&*&'$&' B&%&$ "o$& Po'$&'& "o$& S'&7&' "&,+&$#' B#'&=&' "&,+&$#' "&+,& H,, "&,+&$#' "#$&+&' "&,+&$#' "&=o' U$&%& "&,+&$#' ",, R&=& "&,+&$#' L&'6& "&,+&$#' M#&7 "&,+&$#' Po'$&'& "&,+&$#' S&*& "&,+&$#' S&'&, "&,+&$#' S'$&' "&,+&$#' S#&6&, "&*&'$&' T#'&< "o$& P&&'&%&=& "&,+&$#' B&%$o S#&$&' "&,+&$#' B&%$o T*,% "&,+&$#' B&%$o U$&%& "&,+&$#' G,',' M& "&,+&$#' "&+,& "&,+&$#' "&$'&' "&,+&$#' "o$&7&%'' B&%&$ "&,+&$#' "o$&7&%'' T*,% "&,+&$#' L&*&'6&, "&,+&$#' M,%,' R&=& "&,+&$#' P,&' P&, "&,+&$#' S#%,=&' "&,+&$#' S,&*&%& "&*&'$&'
42
S#&$&' 34. 35. 3. 3!. 38. 3. 3!0. 3!1. 3!2. 3!3. 3!4. 3!5. 3!. 3!!. 3!8. 3!. 380. 381. 382. 383. 384. 385. 38. 38!. 388. 38. 30. 31. 32. 33. 34.
22.01 22.02 22.03 22.04 22.05 22.0 22.0! 22.08 22.0 22.10 22.11 22.12 22.13 23.00 23.01 23.02 23.03 23.05 23.0! 23.08 23.0 23.10 23.11 23.12 24.00 24.01 24.02 24.03 24.04 24.05 25.00
35. 3. 3!. 38. 3. 400. 401.
25.01 25.02 25.03 25.04 25.05 25.0 25.0!
402.
25.08
403. 404. 405. 40. 40!. 408.
25.0 25.10 25.11 25.12 25.13 25.14
40. 410. 411.
25.15 2.00 2.01
"o$& B&'@&%*&' "o$& B&'@&% B&%, "&,+&$#' B&&'&' "&,+&$#' B&'@&% "&,+&$#' B&%$o ",&& "&,+&$#' H,, S,'& S#&$&' "&,+&$#' H,, S,'& T#'&< "&,+&$#' H,, S,'& U$&%& "&,+&$#' "o$&&%, "&,+&$#' T&&o' "&,+&$#' T&'&< B,*, "&,+&$#' T&'&< L&,$ "&,+&$#' T&+' "&*&'$&' T*,% "o$& S&*&%'6& "o$& B&+&+&' "o$& Bo'$&' "&,+&$#' B#%&, "&,+&$#' ",$& B&%&$ "&,+&$#' ",$& "#%$&'#&%& "&,+&$#' ",$& T*,% "&,+&$#' P&'&@&* P&#% U$&%& "&,+&$#' P&#% "&,+&$#' M&<&&* U, "&*&'$&' U$&%& "o$& T&%&&' "&,+&$#' M&'&, "&,+&$#' T&'& T6,' "&,+&$#' B,,'&' "&,+&$#' N,',&' P%o' S,&7# U$&%& "o$& M&'&6o "o$& "o$&*o&, "o$& B$,' "o$& To*o
43
412. 413. 414. 415. 41. 41!. 418. 41. 420. 421. 422. 423. 424. 425. 42. 42!. 428. 42. 430. 431. 432. 433. 434. 435. 43. 43!. 438. 43. 440. 441. 442. 443. 444. 445. 44. 44!. 448. 44. 450. 451. 452. 453. 454. 455. 45. 45!. 458. 45. 40. 41. 42. 43. 44.
2.02 2.03 2.04 2.05 2.0 2.0! 2.08 2.0 2.10 2.11 2.12 2.13 2!.00 2!.01 2!.02 2!.03 2!.04 2!.05 2!.0 2!.0! 2!.08 2!.0 2!.10 2!.11 2!.12 2!.13 2!.14 2!.15 2!.1 2!.1! 2!.18 2!.1 2!.20 2!.21 2!.22 2!.23 2!.24 28.00 28.01 28.02 28.03 28.04 28.05 28.0 28.0! 28.08 28.0 28.10 28.11 28.12 28.13 28.14 28.15
"&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#'
B&'& B&'& "#+,&,&' B,o Do'&& Mo%o7& P&% Mo,$o' Poo To@o U'& U'& To To S B&'& L&,$ Mo%o7& U$&%&
S,&7# S#&$&' "o$& M&&&% "o$& P&%# P&%# "o$& P&o+o "&,+&$#' Bo'# "&,+&$#' B,,,*& "&,+&$#' E'%#&' "&,+&$#' Go7& "&,+&$#' -#'#+o'$o "&,+&$#' L,7, "&,+&$#' L,7, T*,% "&,+&$#' L,7, U$&%& "&,+&$#' M&%o "&,+&$#' P&'#+ "&,+&$#' P'%&' "&,+&$#' S6#'%#' R&++&' "&,+&$#' S'@& "&,+&$#' So++#' "&,+&$#' T&&&% "&,+&$#' T&'&$o%&@& "&,+&$#' W&@o "&,+&$#' To%&@& U$&%& "&,+&$#' S#&=&% "&,+&$#' B&'$&#' "&,+&$#' B&%%, S,&7# T#'&%& "o$& "#'6&% "o$& B&, B&, "&,+&$#' Bo*&'& "&,+&$#' B,$o' "&,+&$#' "o'&7# "&,+&$#' "o&& "&,+&$#' "o&& U$&%& "&,+&$#' "o'&7# S#&$&' "&,+&$#' M,'& "&,+&$#' W&&$o "&,+&$#' "o'&7# U$&%& "&,+&$#' B,$o' U$&%& "&,+&$#' "o&& T*,% "&,+&$#' "o'&7# "#+,&,&' "&,+&$#' M,'& B&%&$
44
45. 4. 4!. 48. 4. 4!0. 4!1. 4!2. 4!3. 4!4. 4!5. 4!. 4!!. 4!8. 4!. 480. 481. 482. 483. 484. 485. 48. 48!. 488. 48. 40. 41. 42. 43. 44. 45. 4. 4!. 48. 4. 500. 501. 502. 503. 504. 505. 50. 50!. 508. 50. 510. 511. 512. 513. 514. 515. 51. 51!.
28.1 28.1! 2.00 2.01 2.02 2.03 2.04 2.05 2.0 30.00 30.01 30.02 30.03 30.04 30.05 30.0 31.00 31.01 31.02 31.03 31.04 31.05 31.0 31.0! 31.08 31.0 31.10 31.11 32.00 32.01 32.02 32.03 32.04 32.05 32.0 32.0! 32.08 32.0 32.10 33.00 33.01 33.02 33.03 33.04 33.05 33.0 33.0! 33.08 33.0 33.10 33.11 33.12 33.13
"&,+&$#' B,$o' T#'&< "&,+&$#' B,$o' S#&$&' Go%o'$&o "o$& Go%o'$&o "&,+&$#' Bo&#*o "&,+&$#' Bo'# Bo&'o "&,+&$#' Go%o'$&o "&,+&$#' Go%o'$&o U$&%& "&,+&$#' Po<,7&$o S,&7# B&%&$ "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#'
M&*,@, M&@#'# M&*,@, U$&%& M&*&& Po#7& M&'6&% M&*,@, T#'&<
M&,, "o$& A*o' "o$& T,& "&,+&$#' B,%, "&,+&$#' "#+,&,&' A%, "&,+&$#' S#%&* B&&' B&%&$ "&,+&$#' S#%&* B&&' T*,% "&,+&$#' M&,, T#'&< "&,+&$#' M&,, T#'&%& "&,+&$#' M&,, T#'&%& B&%&$ "&,+&$#' M&,, B&%&$ D&=& "&,+&$#' B,%, S#&$&' M&,, U$&%& "o$& T#%'&$# "o$& T6o%# "#+,&,&' "&,+&$#' H&*&<#%& B&%&$ "&,+&$#' H&*&<#%& S#&$&' "&,+&$#' H&*&<#%& T#'&< "&,+&$#' H&*&<#%& T*,% "&,+&$#' H&*&<#%& U$&%& "&,+&$#' "#+,&,&' S,& "&,+&$#' Mo%o$& "&,+&$#' P,&, T&&, P&+,& "o$& -&=&+,%& "&,+&$#' A*&$ "&,+&$#' B& N,*;o% "&,+&$#' Bo#' Do# "&,+&$#' -&=&+,%& "&,+&$#' -&=&7@&=& "&,+&$#' "##%o* "&,+&$#' M&++ "&,+&$#' M#%&,# "&,+&$#' M*& "&,+&$#' P&'& "&,+&$#' P#,','&' B'$&' "&,+&$#' P,'9& -&=&
45
518. 51. 520. 521. 522. 523. 524. 525. 52. 52!. 528. 52. 530. 531. 532. 533. 534. 535. 53. 53!. 538. 53. 540. 541. 542. 543. 544. 545. 54. 54!.
33.14 33.15 33.1 33.1! 33.18 33.1 33.20 33.21 33.22 33.23 33.24 33.25 33.2 33.2! 33.28 33.2 34.00 34.01 34.02 34.03 34.04 34.05 34.0 34.0! 34.08 34.0 34.10 34.11 34.12 34.13
"&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#' "&,+&$#'
S&%* M#*#%&*o R&=& S,+o% To&%& C&<,*o C&+#' W&%o+#' W&%o+#' N&%# M#*#%&*o T#'&< C&*o L&''= -&=& N6,& P,'9& Do=& D=& I'$&' -&=&
P&+,& B&%&$ "o$& So%o' "&,+&$#' F& ;& "&,+&$#' "&*&'& "&,+&$#' "#+,&,&' R&@& A*+&$ "&,+&$#' M&'o7&% "&,+&$#' So%o' S#&$&' "&,+&$#' T#, B'$,' "&,+&$#' So%o' "&,+&$#' T#, Wo'6&*& "&,+&$#' T&*%&,7 "&,+&$#' M&=%&$ "&,+&$#' M&'o7&% S#&$&' "&,+&$#' P#,','&' A%;&
4
B.
FORMULIR MODEL B.1
PENERIMAAN LAPORAN No*o%
:..........................
N&o'&
::::.
P%o'
::::..
"&,+&$#'/"o$& ::::. "#9&*&$&'
::::.
D#&/"#,%&<&' ::::. 1.
P#&+o% &.
N&*&
.............................................
.
No*o% I6#'$$&("TP/P&+o%/SIM)
.............................................
9.
T#*+&$/T L&<%
.............................................
6.
-#' "#&*'
.............................................
#.
P##%@&&'
.............................................
;.
"#7&%&'#&%&&'
.............................................
.
A&*&$
.............................................
<. No.T#+/HP
.............................................
.
F&
.............................................
EM&
.............................................
@. 2.
3.
P#%$7& =&' 6&+o%&' &.
P#%$7&
..............................................
.
T#*+&$ "#@&6&'
..............................................
9.
W&$, "#@&6&'
..............................................
6.
H&% 6&' T&'& 6#$&<,
..............................................
#.
T#%&+o%
..............................................
;.
A&*&$ T#%&+o%
..............................................
.
No.T#+/HP T#%&+o%
..............................................
S& & 1. N&*&
..............................................
4!
4.
A&*&$ No.T#+/H+
.............................................. ..............................................
2. N&*& A&*&$ No.T#+/H+
.............................................. .............................................. ..............................................
3. N&*& A&*&$ No.T#+/H+
.............................................. .............................................. ..............................................
B,$B,$
&. ......................................................................................................... . ......................................................................................................... 9. ......................................................................................................... 6. ......................................................................................................... #. ......................................................................................................... 5.
U%&&' '&$ #@&6&' ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::........... ::::::::::::::::::::::::::::::::...........
D&+o%&' 6 H&% 6&' T&'& W&$,/@&*
S&=& *#'=&$&&' &<7& &+o%&' ' &6&&< =&' ##'&%#'&%'=& 6&' &=& #%#6& *#*+#%$&','@&7&&''=& 6 <&6&+&' <,,*.
P#'#%*& L&+o%&'
P#&+o%
:::::::..
:::::::::
CAP
"#$#%&'&' +#'o*o%&' 6#,&&' 6#'&' &*+%&' +#'o*o%&' 6&' 6 #$#&<
48
<& &@&' &7& *#'=&$&&' =&%&$ ;o%* 6&' *&$#% &+o%&' $#%+#',< $6& 7&@ 6 @& &&*&$ T#%&+o%/S& $#*+&$ $'& #'&+/$6& 6#$&<, 9,,+ 6#,$&' 6,,'/6#&/#,%&<&'
4
.
FORMULIR MODEL B.2
FORMULIR TEMUAN No*o%
:........................
N&o'&
:::::::.::.
P%o'
::::::::.:.
"&,+&$#'/"o$& :::::::.::. "#9&*&$&'
:::::::.::.
D#&/"#,%&<&' :::::::.::. 1. D&$&P#'&7& C&' M#'#*,&'
&. N&*&
.............................................
. -&&$&'
.............................................
9. A&*&$
.............................................
2. P#%$7& =&' 6$#*,&'
&. P#%$7&
.............................................................
. T#*+&$ "#@&6&'
.............................................................
9. W&$, "#@&6&'
.............................................................
6. H&% 6&' T&'& 6$#*,&'
.............................................................
#. T#%&+o%
.............................................................
;.
A&*&$ T#%&+o%
.............................................................
. No.T#+/HP T#%&+o%
.............................................................
3. S& &
1.
N&*&
.................................................................................
A&*&$
.................................................................................
No.T#+/H+
.................................................................................
2. N&*&
.................................................................................
A&*&$
.................................................................................
No.T#+/H+
.................................................................................
3. N&*&
.................................................................................
A&*&$
.................................................................................
No.T#+/H+
.................................................................................
50
4. B,$B,$
&. . 9. 6.
............................................................................................................... ............................................................................................................... ............................................................................................................... ...............................................................................................................
5. U%&&' '&$ #@&6&' ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... ......................................................................................................................................... .............................
........................ $&'&...................... B&7&,/B&7&, P%o'...../B&7&, "&/"o$&......../P&'7&, "#9&*&$&'........... ($&'6& $&'&' 6&' '&*& @#&) (@&&$&') "#$#%&'&' * penomoran disesuaikan dengan lampiran penomoran ** jika alamat Terlapor/Saksi tempat tinggal lengkap/tidak diketahui, cukup disebutkan dusun/desa/kelurahan
51
D.
FORMULIR MODEL B.3
TANDA BU"TI PENERIMAAN LAPORAN NOMOR ...................................... ...
T#&< 6$#%*& 6&% N&*& T#*+&$ T&'& L&<%
A&*&$
No.T#+/HP
H&%6&'T&'&
W&$,
Do,*#'
1. .......................................... 2. .......................................... 3. ..........................................
L&+o%&' 6,&&' +#&'&%&' P#*, DPR/DPD/DPRD PRO>INSI/DPRD "ABUPATEN/"OTA &$&, P#*, P%#6#' 6&' W& P%#6#') P%o'.............../ "&,+&$#'................/ "o$&...............) T&<,'...............
o#<
CAP
D$#%*&
52
P#'#%*& L&+o%&'
P#&+o%
53
"#$#%&'&' +#'o*o%&' 6&*&&' 6#'&' 'o*o% &+o%&' 6 $#*+&$ $&'& ,&' 6&' $&<,' 6$&'6&$&'&'
54
E.
FORMULIR MODEL B.4
"OP PENGAWAS PEMILU
No*o% S;&$ L&*+%&' H&
:::::::: ......... ............. P#*+&<&' T#*,&'/L&+o%&' D,&&' P#&'&%&' P#*,....
"#+&6& C$<. "#$,& B&7&, P%o'/B&7&, "&,+&$#'/P&'7&, "&,+&$#'/"o$& 6 ::::::::. 1. D&&% &. U'6&'U'6&' No*o% ! T&<,' 201! $#'$&' P#*<&' U*,* . P#%&$,%&' B&6&' P#'&7& P#*<&' U*,* No*o% ...... T&<,' 2018 $#'$&' P#'&'&'&' T#*,&' 6&' L&+o%&' P#&'&%&' P#*<&' U*,*. 2. M#''6&&'@,$ T#*,&'/L&+o%&' 6,&&' +#&'&%&' =&' $#&< 6$,&'&' 6&&* ;o%*... 6#'&' 'o*o%.....$&'&... $#%&$.... 6#'&' ' B&7&,/B&7&, P%o'/B&7&, "&,+&$#'/o$&/ *#*+&<&' +#'&'&'&' T#*,&'/L&+o%&' 6*&,6 #+&6& B&7&, P%o'/B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&' 3. S#<,,'&' 6#'&' <& $#%#,$ 6*'$& #+&6& B&7&, P%o'/B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&','$, ##%& *#''6&&'@,$ T#*,&'/L&+o%&' 6*&,6 #,& 6#'&' +#%&$,%&' +#%,'6&','6&'&' 6&' *#&+o%&' #+&6& B&7&,/B&7&, P%o'/B&7&, "&,+&$#'/"o$&/ +&6& ##*+&$&' +#%$&*& $#%&$ 6#'&' +#%#*&'&' +#'&'&'&' T#*,&'/L&+o%&' $#%#,$. D#*&' 6&*+&&' &$& +#%<&$&''=& 6,9&+&' $#%*&&<.
"#$,& P#'&7& P#*,................ CAP
"#$#%&'&' D#,&&' 6#'&' P#&'&%&' P#*,. o%#$ =&' $6& +#%, T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&
55
F.
FORMULIR MODEL B.5
"A-IAN AWAL DUGAAN PELANGGARAN I.
B&<7& $#%<&6&+ L&+o%&' 6,&&' P#&'&%&' =&' 6&*+&&' o#< &. N&*& . A&*&$ 9. P##%@&&'
II.
U%&&' +#%$7& 6,&&' +#&'&%&' =&' 6&+o%&' (6,&&' +&& =&' 6&'&%) ............................................................................................................ ............................................................................................................
III.
D&,&' &'& $#%<&6&+ #$#%+#',<&' =&%&$ ;o%* 6&' *&$#% &+o%&' #&& #%,$ &. S=&%&$ Fo%* ....................................................................................................... ....................................................................................................... . S=&%&$ M&$#% ....................................................................................................... ....................................................................................................... 9. ....................................................................................................... .......................
I>.
"#*+,&' L&+o%&' *#*#',< =&%&$ ;o%* 6&' *&$#% &$&, L&+o%&' $6& *#*#',< =&%&$ ;o%* 6&'/&$&, *&$#% &$&, L&+o%&' $6& 6&+&$ 6%#$%& &%#'& $#&< 6&+o%&' +&6& P#'&7& P#*, 6$'&$&' $#%$#'$,
>.
R#o*#'6& A&% P#&+o% ##%& *#*#',< ##'&+&' =&%&$ ;o%*/&$&, *&$#% &+o%&' +&' &*&$ 3 <&% #%@& #@& &+o%&' 6$#%*& =&$, #%,+&.....
CAP
PENGAWAS PEMILU.............. ............................
............................................. "#$#%&'&' No*o% &*& 6#'&' ;o%*,% +#'#%*&&' &+o%&' D#,&&' 6#'&' $'&$&' +#'&7& +#*, D#,&&' 6#'&' =&%&$ ;o%*/*&$#% =&' #,* 6#'&+ o#< P#&+o% D#,&&' 6#'&' '&*& #*&&.
5
G.
FORMULIR MODEL B.
"OP PENGAWAS PEMILU
No*o% H&
U'6&'&' "&%;&
"#+&6& C$< :::::::::::::: 6 :::::::............... :.. 1. D&&% &. U'6&'U'6&' No*o% ! T&<,' 201! $#'$&' P#*<&' U*,* . P#%&$,%&' B&6&' P#'&7& P#*<&' U*,* No*o% ...... T&<,' 2018 $#'$&' P#'&'&'&' T#*,&' 6&' L&+o%&' P#&'&%&' P#*<&' U*,*. 2. B#%6&&%&' L&+o%&'/T#*,&' No*o%:::::::.. #%&*& ' &* B&7&,/B&7&, P%o'/B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&' *#','6&' S6%.::::::::::::.. ,'$, *#*#%&' #$#%&'&' 6&&* &%;& +#%<&................................................................................................ 3. "&%;& &&' 6&&'&&' +&6& &. H&% 6&' T&'&
. P,,
9. T#*+&$
6. B#%$#*, 6#'&'
D#*&' ,'$, *#'@&6 *&,*.
PENGAWAS PEMILU.............. "ETUA CAP
............................................ "#$#%&'&' o%#$/<&+, =&' $6& +#%,. U%&&' #9&%& @#& &%;& =&' &&' 6&,&'. T#*+&$ $&'& ,&' $&<,' 6#,&&' S#,& 6#'&' '&*& #*&&.
5!
H.
FORMULIR MODEL B.!
"OP PENGAWAS PEMILU "ETERANGAN/"LARIFI"ASI DI BAWAH SUMPAH/-AN-I
P#%$&'=&&' A+&&< S&,6&%& #%#6& ,*+&
*#*#%&'
#$#%&'&'/&%;&
6&7&<
-&7&&' C& &=& #%#6&/$6& #%#6& ::::..
P&6& <&% ' :: $&'& :.,&' ::. +,, :::WIB/WITA/WIT &=&
B#%#6& #%,*+&
D#* A&< (& =&' #%&&*& I&*)/ :::. (& =&' #%&&*& :::...)&<7& &=& &&' *#*#% #$#%&'&'/&%;& =&' ##'&%'=& 6&' $6& &' 6&%+&6& =&' ##'&%'=&.
D#*&' ,*+&
S&=& =&' #%,*+&
M#$#%& R+ 000
::::::::::. (N&*& 6&' $&'6&$&'&')
"#$#%&'&' D#,&&' 6#'&' &&*&/#+#%9&=&&' +<& =&' #%,*+&<. D#,&&' 6#'&' 6,&&' +#&'&%&' =&' 6&+o%&'.
58
I.
FORMULIR MODEL B.8
"OP PENGAWAS PEMILU "ETERANGAN AHLI DI BAWAH SUMPAH/-AN-I
P#%$&'=&&' A+&&< S&,6&%& #%#6& *#*#%&' #$#%&'&' 6&7&< ,*+&
-&7&&' C& &=& #%#6&/$6& #%#6& ::::..
P&6& <&% ' :: $&'& :.,&' ::. +,, :::WIB/WITA/WIT &=&
B#%#6& #%,*+&
D#* A&< (& =&' #%&&*& I&*)/ :::. (& =&' #%&&*& :::...)&<7& &=& &&' *#*#% #$#%&'&' =&' #&&'=& #,& 6#'&' #&<&' =&' &=& *.
D#*&' ,*+&
S&=& =&' #%,*+&
M#$#%& R+ 000
::::::::::. (N&*& 6&' $&'6&$&'&')
"#$#%&'&' D#,&&' 6#'&' &&*&/#+#%9&=&&' +<& =&' #%,*+&<. D#,&&' 6#'&' 6,&&' +#&'&%&' =&' 6&+o%&'.
5
-.
FORMULIR MODEL B.
"OP PENGAWAS PEMILU BERITA AARA "LARIFI"ASI
P&6& <&% ' :: T&'& :.,&' ::.$&<,'..... +,, ::: WIB/ WITA/ WIT&=&
A'o$&
B&7&,/B&7&,
P%o'/B&7&,
"&,+&$#'/"o$&/P&'7&,
"#9&*&$&' 6&' #%$'6& &$& '&*& #*&& (B&7&,/B&7&, P%o'/ B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&'::::)
6&'/&$&,
P#@&&$
S$%,$,%&/T#'&&
A</T*
A$#'/S$&;
B&7&,/B&7&,
P%o'/B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&' 6&' #%$'6& &$& '&*&
#*&&
(B&7&,/
B&7&,
P%o'/
B&7&,
"&,+&$#'/"o$&/P&'7&, "#9&*&$&'::::)$#&< *#*'$& #$#%&'&' 6&% #o%&' =&' #%'&*&
D&<%&' 6 .......... $&'& .......... B,&' ..........T&<,' ..........
(,*,%
..........T&<,') +##%@&&' .......... A&*& .......... "#7&%&'#&%&&' I'6o'#& $#*+&$ $'& 6...........................................................................................
D&
(.................)
66#'&%
#$#%&'&''=&
#&&
::::::::::.
$#%&$ 6#'&'::::::::::.............................................................................. ...........::::::::::..............................................................................
A$& +#%$&'=&&' S&=& #&, A'o$& B&7&,/ B&7&, P%o'/ B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&' 6&'/&$&, P#@&&$ S$%,$,%&/T#'&& A</T*
A$#'/S$&;
B&7&,/
B&7&,
P%o'/
B&7&,
"&,+&$#'/"o$&/P&'7&, "#9&*&$&' =&' #%&',$&' *#'@&7& #%$&
0
*#'#%&'&' #&& #%,$ PERTANCAAN P#%$&'=&&' P#*,& 1.
A+&&< S&,6&%& +&6& <&% ' #%&6& 6&&* o'6 #<&$ @&*&' 6&' %o<&' ,'$, *#*#%&' #$#%&'&' &$&, @&7&&' $#%&$ 6#'&' &+o%&' 6 &$& :::::J
01. .......................-&7&&'). 2.
A+&&< +&6& <&% ' (#,& $&'& ,&' 6&' $&<,' $#%#,$ 6 &$&) S&,6&%& #%#6& ,'$, *#*#%&' #$#%&'&' &$&, @&7&&' $#%&$ 6#'&'&6&'=&.................J 02. .......................-&7&&').
3.
M#'#%$&< S&,6&%& *#'&+& 6*'$& #$#%&'&' #+#%$ &&$ 'J -#&&'K 03. .......................-&7&&').
P#%$&'=&&' I (B#%&$&' 6#'&' "&,) 04. ............................................................................................................. 04. .......................-&7&&'). 05. ............................................................................................................. 05. .......................-&7&&'). 0. ............................................................................................................. 0. .......................-&7&&').
P#%$&'=&&' P#',$,+ !.
A+&&< *#',%,$ S&,6&%& #*,& #$#%&'&' &$&, @&7&&' =&' S&,6&%& &*+&&' ,6&< #'&% 6&' 6&+&$ 6+#%$&',' @&7&&' 6 6#+&' <,,*J 0!. .......................-&7&&').
8.
A+&&< *&< &6& #$#%&'&' &' &$&, #$#%&'&' $&*&<&' =&' '' S&,6&%& &*+&&'J 08. .......................-&7&&').
.
A+&&< S&,6&%& #%#6& ,'$, *#*#%&' #$#%&'&' #*&
1
&+&& 6+#%,&' J 0. .......................-&7&&'). 10.
A+&&< S&,6&%& 6&&* *#*#% #$#%&'&' &$&, @&7&&' *#%&&
$#%$#&' &$&, $#%+&& &%#'& $#&'&' o#< +#*#%& &$&, +<& &'J. 10. .......................-&7&&').
S#$#&< #$#%&'&' 6#%&'/6&*+&&' <&'=& 6&9&&' #*& #+&6& +<& =&' *#*#% #$#%&'&'/@&7&&' 6#'&' &<&& =&' @#& 6&' *,6&< 6*#'#%$. S#$#&< 6&, ##'&%&' &$& #$#%&'&'/@&7&&' =&'
6&*+&&'
*#*,,<&'
#+&6&
P#'&7&
P#*,
+#*#%
#$#%&'&'
$&'6& $&'&' 6 &$& *#$#%& R+..000 #+#%$ 6 &7&<
'.
CANG MEMBERI "ETERANGAN
(::::::::::::::)
D#*&' #%$& &9&%& &%;& ' 6,&$ 6#'&' ##'&% #'&%'=& #*,6&' 6$,$,+ 6&' 6$&'6& $&'&' 6 ................... +&6& P,,........... <&% .......... $&'& .......... T&<,'20...........
CANG MEMINTA "ETERANGAN
( ::::::::::::..)
"#$#%&'&' o%#$ =&' $6& +#%, P#'&7& P#*, *#'&*&< +#%$&'=&&' #< 6#$& ,'$, *#'& ';o%*& &$&, ##,&&' #$#%&'&' & #%$& *#'6&+&$&' ,$ 6#'&' ,$&' 6&' @,*&< =&' 6#,&&' 6#'&' #,$,<&' +#'&'&'&' &,.
2
".
FORMULIR MODEL B.10 "A-IAN DUGAAN PELANGGARAN No*o% .....................
I.
"&, Po
N&o'&
::::.
P%o'
::::.
"&,+&$#'/"o$&
::::.
"#9&*&$&'
::::.
D#&/"#,%&<&'
::::.
::::::::::::::::::::................. ::::::::::::::::::::.::::: ::::::::......................................................
II. D&$& 1. P#&+o%/P#'#*, 2. P##%@&&'/-&&$&' 3. A&*&$ 4. T#%&+o% 5. P##%@&&' . A&*&$ !. T&'& L&+o%&'/T#*,&' 8. T&'& P#%$7& . B,$B,$
III. "&@&' 1. D&&% H,,* 2. F&$& 3. A'& &. T#'$&' T#*,&'/L&+o%&' . T#'$&' P#'#*,/P#&+o% 9. T#'$&' T#%&+o% 6. T#'$&' P<& C&' 66,& #&& P#&, #. T#'$&' W&$, T#*,&'/L&+o%&' ;. T#'$&' 6,&&' +#&'&%&' I>. "#*+,&'
............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. ............................................. .............................................
::::::::::::::...........::::::. ::::::::::::::...........::::::. ::::::::::::::...........::::::. ::::::::::::::...........::::::.
3
>. R#o*#'6&
::::::::::::::...........::::::. ::::::::::::::...........::::::. ::::::::::::::...........::::::. ::::::::::::::...........::::::.
PENGAWAS PEMILU.............. ............................ CAP
.............................................
"#$#%&'&' No*o% &*& 6#'&' ;o%*,% +#'#%*&&' &+o%&'/T#*,&' P#&+o% ,'$, L&+o%&' P#&'&%&' P#*, 6&' P#'&7& P#*, ,'$, T#*,&' D,&&' P#&'&%&'. 6 @& &6& +<& =&' 66,& #&& P#&, =&' *#&,&' +#&'&%&' #&' T#%&+o% T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&. B6&' P#'&'&'&' P#&'&%&'.
4
L.
FORMULIR MODEL B.11
"OP PENGAWAS PEMILU
No*o% H&
:::::::: P#'#%,&' P#&'&%&' "o6# E$ P#'=##'&%& P#*,
"#+&6& C$<. "#$,& D#7&' "#
"#$,& P#'&7& P#*,................ CAP
"#$#%&'&' o%#$ =&' $6& +#%,. T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&.
5
M.
FORMULIR MODEL B.12
"OP PENGAWAS PEMILU
No*o% H&
:::::::: P#'#%,&' T'6& P6&'& P#*,
"#+&6& C$<. "&+o%/"&+o6&/"&+o%#$&#/"&+o%#$&/"&+o%# 6 ::::::::. 1. D&&% &. U'6&'U'6&' No*o% ! T&<,' 201! $#'$&' P#*<&' U*,* . P#%&$,%&' B&6&' P#'&7& P#*<&' U*,* No*o% ...... T&<,' 2018 $#'$&' P#'&'&'&' T#*,&' 6&' L&+o%&' P#&'&%&' P#*<&' U*,*. 2.
B#%6&&%&' #+,$,&' %&+&$ +#'o A'o$& B&7&,/B&7&, P%o'/B&7&, "&,+&$#'/"o$& $#%<&6&+ 6,&&' P#&'&%&' P#*, #&&*&'& 6*&,66&&* T#*,&'/L&+o%&' No*o% ::::: ($#%&*+%) T#*,&'/L&+o%&' 6*&,6 66,& *#*#',< ,',%,',% $'6& +6&'& P#*, 6&' #&'@,$'=& 6$#%,&' #+&6& "&+o%/"&+o6&/"&+o%#$&#/"&+o%#$&/"&+o%# ,'$, 6$'6&&'@,$ #,& +#%&$,%&' +#%,'6&','6&'&' =&' #%&,.
3.
D#*&' ,'$, *#'@&6 *&,*.
"#$,& P#'&7& P#*,................
CAP
"#$#%&'&' * o%#$ =&' $6& +#%,. T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&.
N.
FORMULIR MODEL B.13 (formulir yang kami tambahkan)
"OP PENGAWAS PEMILU
No*o% H&
:::::::: P#'#%,&' P#&'&%&' A6*'$%&$; P#*,
"#+&6& C$<. "#$,& PP"............ 6 ::::::::. 1. D&&% &. U'6&'U'6&' No*o% ! T&<,' 201! $#'$&' P#*<&' U*,* . P#%&$,%&' B&6&' P#'&7& P#*<&' U*,* No*o% ...... T&<,' 2018 $#'$&' P#'&'&'&' T#*,&' 6&' L&+o%&' P#&'&%&' P#*<&' U*,*. 2.
3.
B#%6&&%&' #+,$,&' %&+&$ +#'o A'o$& P&'7&, "#9&*&$&' $#%<&6&+ 6,&&' +#&'&%&' +#*, #&&*&'& 6*&,6 6&&* T#*,&'/L&+o%&' No*o% :::::($#%&*+%) T#*,&'/L&+o%&' 6*&,6 66,& *#%,+&&' +#&'&%&' ......................... 6&' #&'@,$'=& 6$#%,&' #+&6& ................................................. ,'$, 6$'6&&'@,$ #,& +#%&$,%&' +#%,'6&','6&'&' =&' #%&,. D#*&' ,'$, *#'@&6 *&,*.
"#$,& P#'&7& P#*,................ CAP
"#$#%&'&' o%#$ =&' $6& +#%,. T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&.
!
O.
FORMULIR MODEL B.14
"OP PENGAWAS PEMILU
No*o% H&
:::::::: P#'#%,&' P#&'&%&' 6 ,&% P#%,'6&'U'6&'&' P#*,
"#+&6& C$<. .................................................................... 6 ::::::::. 1. D&&% &. U'6&'U'6&' No*o% ! T&<,' 201! $#'$&' P#*<&' U*,* . P#%&$,%&' B&6&' P#'&7& P#*<&' U*,* No*o% ...... T&<,' 201! $#'$&' P#'&'&'&' T#*,&' 6&' L&+o%&' P#&'&%&' P#*<&' U*,*. 2.
3.
B#%6&&%&' #+,$,&' %&+&$ +#'o A'o$& B&7&,/B&7&, P%o'/B&7&, "&,+&$#'/"o$&/P&'7&, "#9&*&$&' $#%<&6&+ 6,&&' +#&'&%&' +#*, #&&*&'& 6*&,66&&* T#*,&'/L&+o%&' No*o% :::::($#%&*+%) T#*,&'/L&+o%&' 6*&,666,& *#%,+&&' +#&'&%&' ......................... 6&' #&'@,$'=& 6$#%,&' #+&6& ................................................. ,'$, 6$'6&&'@,$ #,& +#%&$,%&' +#%,'6&','6&'&' =&' #%&,. D#*&' ,'$, *#'@&6 *&,*.
"#$,& P#'&7& P#*,................ CAP
"#$#%&'&' * o%#$ =&' $6& +#%,. T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&.
8
P.
FORMULIR MODEL B.15
"OP PENGAWAS PEMILU
PEMBERITAHUAN TENTANG STATUS LAPORAN/TEMUAN B#%6&&%&' <& +#'#$&' 6&' +#*#%&&' $#%<&6&+ &+o%&'/$#*,&' =&' *&, 6&' <& &@&' P#'&7& P#*, 6#%$&<,&' $&$, &+o%&'/$#*,&' #&& #%,$ NO
NAMA PELAPOR/PENGAWAS PEMILU DAN TERLAPOR/PELA"U
NOMOR LAPORAN/ TEMUAN
STATUS LAPORAN/ TEMUAN
INSTANSI TU-UAN/ ALASAN
&$&$&' 1. D$'6&&'@,$ # '$&' $,@,&' &. D#7&' "#
D,*,*&' 20..: P#'&7& P#*,..... CAP
($&'6& $&'&' 6&' '&*& @#&)
"#$#%&'&' N&*& P#&+o% o#< $6& 69&'$,*&' @& P#&+o% *#*'$& '&*&'=& 6%&<&&&' $#%&$ 6#'&' ;&$ &+o%&'. o%#$ =&' $6& +#%,. T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&.
!0
.
FORMULIR MODEL B.1
...................................)
No*o% L&*+ P#%<&
....................... ....................... P#%*'$&&' "o%# A$& R#o*#'6& B&7&,/B&7&, P%o'/No*o%............................... T&'&.....................
"#+&6& C$< "#$,& B&6&' P#'&7& P#*<&' U*,*/ "#$,& B&6&' P#'&7& P#*<&' U*,* P%o'::::::::::::::. -&&' ..........................................................
D#'&'
IDENTITAS &. N&*& P#&+o%
........................................................
. -#' "#&*'
........................................................
9. A&*&$
........................................................
6. No*o% T##+o'/HP
........................................................
#. No*o% ;&*
........................................................
;. A&*&$ ,%&$ ##$%o' ........................................................ M#*#%&' ",&& #+&6& 1. ::: 2. ::.. 6$:: #%6&&%&' S,%&$ ",&& "<,, No*o%:::. $&'&::::::: 6&&* <& ' *#*< 6o* 6 "&'$o% ",&&'=& :::::::::::::.:::::::::...... D#'&' ' *#'&@,&' +#%*'$&&' o%# &$& R#o*#'6& B&7&, P%o'/"&/"o$& No*o%::::: $&'&::::: =&' R#o*#'6&'=& &6&&< #&& #%,$
M#%#o*#'6&&' 1. ............ 2. ............ 3. ............
!1
II. TENGGANG WA"TU PENGA-UAN PERMINTAAN "ORE"SI P#&+o% *#'&@,&' +#%*'$&&' o%# &$& %#o*#'6& B&7&, P%o'/"&/"o$&.................... No*o%::: T&'&:::: #+&6& B&6&' P#'&7& P#*<&' U*,* &$&,
B&6&' P#'&7& P#*<&'
U*,* P%o' +&6& $&'&...................... B&<7&
R#o*#'6&
"&,+&$#'/"o$&
B&7&,
.....................
P%o'/B&7&,
6#,&%&'
6&'
6$#%,&'
+&6&
<&% ......... $&'& ............6$.....#<'& $6& *##7&$ &$& 7&$, +#'&@,&'
#&&*&'&
No*o%....T&<,'...
6&$,%
$#'$&'
6&&*
P#'&'&'&'
P&&.....P#%&$,%&' T#*,&'
6&'
B&7&, L&+o%&'
P#&'&%&' P#*<&' U*,* III. ALASAN PERMINTAAN "ORE"SI. P&6& +oo'=& P#%*'$&&' "o%# P#&+o% &6&&< *#'#'& +#'#%&+&' <,,* 6&&* R#o*#'6& B&7&, P%o'/B&7&, "&,+&$#'/"o$& No*o%::::.
T&'&::::.
(Jelaskan
secara
detail
tentang
permohonan koreksi Pelapor atas penerapan hukum dalam Putusan a!aslu Pro"insi /#ab/#ota terhadap $aporan dugaan pelanggaran %dministratif Pemilu/%dministratif TS& Pemilu oleh Pelapor ) #&& #%,$ :::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::: I>. HAL CANG DIMINTA UNTU" DI"ORE"SI B#%6&&%&' &&&'&&&' $#%#,$ 6 &$& *o
,'$,
*#*#%&
6&' *#'o%#
%#o*#'6& B&7&,
P%o' &$&, B&7&, "&,+&$#'/"o$& #&& #%,$ &. M#'#%*& +#%*'$&&' o%# P#&+o% :.(nama Pelapor) :. . M#'=&$&&' *#*&$&&' R#o*#'6& B&7&, P%o'/B&7&, "&,+&$#'/"o$&............... No*o%.................... $&'&................ 9. D$....
!2
D#*&'&<
+#%*'$&&' o%#
P#&+o% 6#'&'
<&%&+&'
B&6&'
P#'&7& P#*,/ B&6&' P#'&7& P#*, 6&+&$ ##%& *#*#%& 6&' *#*,$,&' +#%*'$&&' o%# P#&+o% ' #9&%& &6. Ho%*&$ &* PELAPOR/"UASA PELAPOR 1. N&*& ...................................
($&'6& $&'&')
2. N&*&....................................
($&'6& $&'&')
"#$#%&'&' D $#*+&$ $&'& ,&' 6&' $&<,'
!3
R.
FORMULIR MODEL B.1!
"OP PENGAWAS PEMILU
BERITA AARA HASIL "ORE"SI ATAS LAPORAN/TEMUAN NO MOR........ B#%6&&%&' <& +#'#$&' 6&' +#*#%&&' $#%<&6&+ +#%*'$&&' o%# &$& $#*,&'/&+o%&' No*o%.........=&' 6&@,&' o#<........A6&+,' <& +#*#%&&' o#< P#*#%& "o%# &6&&< #&& #%,$ I.
I6#'$$& P#&+o%
....::::::::::::::::::.
II. W&$, P#'&@,&' "o%#
.............................................................
III. A&&' P#%*'$&&' "o%#
.............................................................
I>. H& =&' 6*'$& ,'$, 6o%# ............................................................ >. P#'6&+&$ H,,* B&7&,/ B&7&, P%o'
.::::::::::::::.....:::
>I. "#*+,&'
............................................................
>I. "#+,$,&'
..::::::::::::::::........
&.
M#',&$&' %#o*#'6&/+#'#%,&' T#*,&' &$&, L&+o%&' B&7&,
.
P%o' &$&, B&7&, "&,+&$#'/"o$& &$&, M#'o%# %#o*#'6&/+#'#%,&' T#*,&' &$&, L&+o%&' B&7&, P%o'
&$&,
B&7&,
"&,+&$#'/o$&
6&'
*#'#%$&'
,%&$
%#o*#'6&/+#'#%,&' =&' &%, #%,+&........
20..:
P#'&7& P#*,.....
P#'&7& P#*,.....
($&'6& $&'&' 6&' '&*& @#&)
($&'6& $&'&' 6&' '&*& @#&)
P#'&7& P#*,.....
($&'6& $&'&' 6&' '&*& @#&)
!4
"#$#%&'&' D#,&&' 6#'&' 'o*o% %#$%& +#%*'$&&' o%#. D#,&&' 6#'&' <& o%#. T#*+&$ $&'& ,&' $&<,'. D#,&&' 6#'&' '&*& #*&&.
