NAMA SATUAN KERJA - Bagi_word_formulir

(TEMPLATE SWAKELOLA - 1?3)

6ATATAN KONDISI DAN 2ASIL SUR<EI

PROPINSI :999999999

TANGGAL SUREI :999999999999

SATKER"SATKER NT :999999999

%UA%A :999999999999

LOKASI :99999999999

NO KEGIATAN URAIAN KEGIATAN KETERANGAN

PETUGAS

NAMA SATUAN KERJA ...

...

KOP SURAT

Nomor : ……….., ..………

Lamira! : " K#a$a %&'.:

P#!!a A!ara!*P#+aa& P#ma& Komi&m#!

K#ia&a! ……… ……….

………

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 SATUAN 2OLUME KETERANGAN

Ba'a!*Ma&#ria-4 T#!aa K#r+a

5 P#ra-a&a!

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!………. ………..

(TEMPLATE SWAKELOLA - 1a) KOP SURAT

SURAT PER!AN!IAN

>n8>4 m36a47ana4an

Pa438 P343r5aan P3n<a;aan #aran< 

Nomor: 

Hi4a P3n?3;ia '>4an '3r'3n8>4 43mi8raan"KSO ma4a 4a6ima8 p3m'>4aan"4ompari7i 73'a<ai '3ri4>8:

SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an<ani ;i  pa;a =ari  8an<<a6  '>6an  8a=>n  H8an<<a6 '>6an ;an 8a=>n ;ii7i ;3n<an =>r>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;a8an<ani SK p3n38apan 73'a<ai PPK No  HNo SK p3n38apan 73'a<ai P35a'a8 P3m'>a8 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<<a6  H8an<<a6 p3n3r'i8an A48a ?an< ;i436>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'a<ai '3ri4>8:

1  Hnama P3n?3;ia 1C 2  Hnama P3n?3;ia 2C  ;78

?an< ma7in<-ma7in< an<<o8an?a '3r8an<<>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<<o8a 43mi8raan ?an< ;i8>n5>4 73'a<ai @a4i6 43mi8raan"KSO >n8>4 '3r8in;a4 a8a7 nama K3mi8raan ?an< '3r43;>;>4an ;i  Ha6ama8 P3n?3;ia @a4i6 43mi8raan '3r;a7ar4an

S?ara8-S?ara8 Um>m Kon8ra4 ?an< 83r6ampir ;a6am Kon8ra4 ini (736an5>8n?a ;i73'>8 P$$r.aan P$n%a4aan aran%B)C

(') P3n?3;ia 73'a<aimana ;in?a8a4an 43pa;a PPK m3mi6i4i 43a=6ian prof37iona6 p3r7oni6 ;an 7>m'3r ;a?a 834ni7 73r8a 836a= m3n?38>5>i >n8>4 m3n?3;ia4an #aran< 737>ai ;3n<an p3r7?ara8an ;an 4383n8>an ;a6am Kon8ra4 iniC

() PPK ;an P3n?3;ia m3n?a8a4an m3mi6i4i 43@3nan<an >n8>4 m3nan;a8an<ani Kon8ra4 ini ;an m3n<i4a8 pi=a4 ?an< ;i@a4i6iC

(;) PPK ;an P3n?3;ia m3n<a4>i ;an m3n?a8a4an 'a=@a 73=>'>n<an ;3n<an p3nan;a8an<anan Kon8ra4 ini ma7in<-ma7in< pi=a4:

1) 836a= ;an 73nan8ia7a ;i'3ri4an 4373mpa8an >n8>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 ;3n<an ini '3r73pa4a8 ;an m3n?38>5>i =a6-=a6 73'a<ai '3ri4>8:

1 H>n8>4 4on8ra4 =ar<a 7a8>an a8a> 4on8ra4 <a'>n<an =ar<a 7a8>an ;an 6>mp 7>m ;i8>6i7 73'a<ai '3ri4>8 :

8o8a6 =ar<a Kon8ra4 a8a> Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) ?an< ;ip3ro63= '3r;a7ar4an 4>an8i8a7 ;an =ar<a 7a8>an p343r5aan 73'a<aimana 83ran8>m ;a6am Daf8ar K>an8i8a7 ;an ,ar<a a;a6a= 73'37ar Rp ( r>pia=)CB

H>n8>4 4on8ra4 6>mp 7>m ;i8>6i7 73'a<ai '3ri4>8:

8o8a6 =ar<a Kon8ra4 a8a> 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 'a<ian ?an< 8i;a4 83rpi7a=4an ;ari Kon8ra4 ini:

a

a;3n;>m S>ra8 P3r5an5ianC

'

po4o4 p3r5an5ianC



7>ra8 p3na@aranC

;

;af8ar 4>an8i8a7 ;an =ar<a (apa'i6a a;a)C

3

7?ara8-7?ara8 4=>7>7 Kon8ra4C

f

7?ara8-7?ara8 >m>m Kon8ra4C

<

7p37ifi4a7i 4=>7>7C

=

7p37ifi4a7i >m>mC

p3r83n8an<an an8ara 4383n8>an ;a6am 7>a8> ;o4>m3n ;3n<an 4383n8>an ;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) m3n<a@a7i ;an m3m3ri47a p343r5aan ?an< ;i6a47ana4an o63= P3n?3;iaC

2) m3min8a 6aporan-6aporan m3n<3nai p36a47anaan p343r5aan ?an< ;i6a4>4an 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 ;3n<an =ar<a ?an< 83ran8>m ;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 ;3n<an =ar<a ?an< 836a= ;i83n8>4an ;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 ;3n<an 5a;@a6 p36a47anaan p343r5aan ?an< 836a= ;i838ap4an ;a6am Kon8ra4C

) m36a47ana4an ;an m3n?3637ai4an p343r5aan 73ara 3rma8 a4>ra8 ;an p3n>= 8an<<>n< 5a@a' ;3n<an m3n?3;ia4an 83na<a 43r5a 'a=an-'a=an p3ra6a8an an<4>8an 43 a8a> ;ari 6apan<an ;an 73<a6a p343r5aan p3rman3n ma>p>n 73m3n8ara ?an< ;ip3r6>4an >n8>4 p36a47anaan p3n?3637aian ;an p3r'ai4an p343r5aan ?an< ;irini ;a6am Kon8ra4C

*) m3m'3ri4an 4383ran<an-4383ran<an ?an< ;ip3r6>4an >n8>4 p3m3ri47aan p36a47anaan ?an< ;i6a4>4an PPKC

+) m3n?3ra=4an =a7i6 p343r5aan 737>ai ;3n<an 5a;@a6 p3n?3ra=an p343r5aan ?an< 836a= ;i838ap4an ;a6am Kon8ra4C

.) m3n<am'i6 6an<4a=-6an<4a= ?an< >4>p m3ma;ai >n8>4 m36in;>nn<an 83mpa8 43r5a ;an m3m'a8a7i p3r>7a4an ;an <an<<>an 43pa;a ma7?ara4a8 ma>p>n mi6i4n?a a4i'a8 43<ia8an P3n?3;ia

* Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<<a6 ?an< ;i838ap4an ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4 ;3n<an 8an<<a6 m>6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'a<aimana ;ia8>r ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4

Un8>4 ;an a8a7 nama  PPK

H8an;a 8an<an ;an ap (5i4a 7a6inan a76i ini >n8>4 P3n?3;ia ma4a r34a84an ma83rai Rp *000- )

Hnama 63n<4ap  H5a'a8an

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

H8an;a 8an<an ;an ap (5i4a 7a6inan a76i ini >n8>4 7a8>an 43r5a PPK ma4a r34a84an ma83rai Rp

*000- )

Hnama 63n<4ap H5a'a8an

(TEMPLATE SWAKELOLA - 13)

SURAT PER!AN!IAN

>n8>4 m36a47ana4an

Pa438 P343r5aan a7a Kon7>68an7i P3roran<an : 

Nomor : 

SURAT PERANIAN ini '3ri4>8 73m>a 6ampirann?a (736an5>8n?a ;i73'>8 Kon8ra4B) ;i'>a8 ;an ;i8an;a8an<ani ;i  pa;a =ari  8an<<a6  '>6an  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;a8an<ani SK p3n38apan 73'a<ai PPK No  Hnomor SK p3n38apan 73'a<ai PPK (736an5>8n?a ;i73'>8 PPK B) ;an  Hnama p3n?3;ia  73'a<ai 83na<a a=6i  Hpo7i7i 83na<a a=6i p3n?3;ia  ?an< '3r8in;a4 >n8>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'a<aimana ;i83ran<4an ;a6am S?ara8-S?ara8 Um>m Kon8ra4 ?an< 83r6ampir ;a6am Kon8ra4 iniC

(') P3n?3;ia 73'a<aimana ;in?a8a4an 43pa;a PPK m3mi6i4i 43a=6ian prof37iona6 p3r7oni6 ;an 7>m'3r ;a?a 834ni7 ;an 836a= m3n?38>5>i >n8>4 m3n?3;ia4an a7a Kon7>68an7i 737>ai ;3n<an p3r7?ara8an ;an 4383n8>an ;a6am Kon8ra4 iniC

() PPK ;an p3n?3;ia m3n?a8a4an m3mi6i4i 43@3nan<an >n8>4 m3nan;a8an<ani Kon8ra4 ini ;an ?an< m3nan;a8an<ani m3mp>n?ai 43@3nan<an >n8>4 m3n<i4a8 pi=a4 ?an< ;i@a4i6iC

(;) PPK ;an p3n?3;ia m3n<a4>i ;an m3n?a8a4an 'a=@a 73=>'>n<an ;3n<an p3nan;a8an<anan Kon8ra4 ini ma7in<-ma7in< pi=a4:

1) 836a= ;an 73nan8ia7a ;i'3ri4an 4373mpa8an >n8>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

;ip3ro63= '3r;a7ar4an rinian 'ia?a 7a8>an p343r5aan 73'a<aimana 83ran8>m ;a6am #3ri8a Aara ,a7i6 K6arifi4a7i ;an N3<o7ia7i T34ni7 ;an #ia?a a;a6a= 73'37ar Rp

( r>pia=)CB

H>n8>4 Kon8ra4 L>mp7>m ;i8>6i7 73'a<ai '3ri4>8 :

JTo8a6 =ar<a Kon8ra4 a8a> Ni6ai Kon8ra4 83rma7>4 Pa5a4 P3r8am'a=an Ni6ai (PPN) 73'a<aimana 83ran8>m ;a6am #3ri8a Aara ,a7i6 K6arifi4a7i ;an N3<o7ia7i T34ni7 ;an #ia?a 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

! Do4>m3n-;o4>m3n '3ri4>8 m3r>pa4an 7a8>-437a8>an ;an 'a<ian ?an< 8i;a4 83rpi7a=4an ;ari Kon8ra4 ini:

a) A;3n;>m 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 p3r83n8an<an an8ara 4383n8>an ;a6am 7>a8> ;o4>m3n ;3n<an 4383n8>an ;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 ;3n<an 4383n8>an Kon8ra4C ;an

') PPK '3r43@a5i'an >n8>4 m36a4>4an p3m'a?aran 43pa;a p3n?3;ia 737>ai ;3n<an 4383n8>an Kon8ra4

* Kon8ra4 ini m>6ai '3r6a4> 3f348if 83r=i8>n< 735a4 8an<<a6 ?an< ;i838ap4an ;3n<an 8an<<a6 m>6ai ;an p3n?3637aian 43736>r>=an p343r5aan 73'a<aimana ;ia8>r ;a6am S?ara8-S?ara8 Um>m"K=>7>7 Kon8ra4

8an<<a6 83r73'>8 ;i a8a7 ;an m36a47ana4an Kon8ra4 737>ai ;3n<an 4383n8>an p3ra8>ran p3r>n;an<->n;an<an ?an< '3r6a4> ;i R3p>'6i4 In;on37ia

Un8>4 ;an a8a7 nama PPK



H8an;a 8an<an ;an ap (5i4a 7a6inan a76i ini >n8>4 P3n?3;ia a7a Kon7>68an7i ma4a r34a84an

ma83rai Rp *000-)

Hnama 63n<4ap  H5a'a8an

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



H8an;a 8an<an (5i4a 7a6inan a76i ini >n8>4 pro?34"7a8>an 43r5a P35a'a8 P3m'>a8 Komi8m3n

ma4a r34a84an ma83rai Rp *000-)

Hnama 63n<4ap  H5a'a8an

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<<a6  '>6an 8a=>n  an8ara ##################################### 736a4> P35a'a8 an< M36a4>4an Tin;a4an an< M3n<a4i'a84an P3n<36>aran An<<aran #36an5a (P35a'a8 P3m'>a8 Komi8m3n) Pa;a Uni8 K3<ia8an  D3par83m3n  736an5>8n?a ;i73'>8 PI2AK KESATU ;an ####################################### 736a4> Oran< P3r73oran<an 736an5>8n?a ;i73'>8 PI2AK KEDUA 736an5>8n?a ;i73'>8 KONTRAK 83r8an<<a6 

MAKA DENGAN INI K3;>a #36a= Pi=a4 m3n?38>5>i 73m>a 4383n8>an ?an< 83ran8>m ;a6am pa7a6-pa7a6 '3ri4>8:

1 TUGAS PI,AK KEDUA:

a PI,AK KEDUA =ar>7 m36a47ana4an La?anan a7a 99999999 ;a6am Ran<4a 999999999 737>ai ;3n<an 5>m6a= @a48>999999 ;an ;i6a47ana4an ;i9999 ' PI,AK KEDUA =ar>7 m36a47ana4an La?anan a7a 99999999 ;a6am Ran<4a

999999999 737>ai ;3n<an 5>m6a= o6>m3 p343r5aan ?an< 83r;iri ;ari9999999 ,ari ;an 8an<<a6 ;im>6ain?a p343r5aan a;a6a=99997ampai ;3n<an99999Apa'i6a PI,AK KEDUA m36a47ana4an p343r5aan m36ampa>i @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 ;3n<an 9999999999 ;an 999999999 (73'a<ai p3nan<<>n< 5a@a' pa438 43<ia8an) ;an

p36a47anaan p343r5aan ?an< '3r7an<4>8an

 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 ;3n<an 4ai4 o63= PI,AK KESATU

2 TUGAS PI,AK KESATU:

a PI,AK KESATU @a5i' m3n?3;ia4an fa7i6i8a7 ?an< ;i73pa4a8i >n8>4 436anaran p36a47anaan p343r5aan

' PI,AK KESATU @a5i' m3m'a?ar 43pa;a PI,AK KEDUA a8a7 p36a47anaan p343r5aan '3r;a7ar4an =ar<a 4on8ra4

! P343r5aan 'oron<an ?an< a4an ;i6a47ana4an 73ni6ai Rp9999999999 (999999999) $ S>ra8 P3r5an5ian ini '3r6a4> ;an m3n<i4a8 K3;>a #36a= Pi=a4 735a4 8an<<a6 ;i8an;a8an<ani

S>ra8 P3rin8a= M>6ai K3r5a ;i83r'i84an 73836a= S>ra8 P3r5an5ian ;i8an;a8an<ani

 K3>a6i 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 K3<ia8an  6 99999999999999999999

999999999999999999999 ' A6ama8 PI,AK KEDUA

 6 9999999999999999999

99999999999999999999

DENGAN DEMIKIAN K3;>a #36a= Pi=a4 836a= 73pa4a8 >n8>4 m3nan;a8an<ani S>ra8 P3r5an5ian ini pa;a 8an<<a6 83r73'>8 ;i a8a7

PI2AK KEDUA PI2AK KESATU

P35a'a8 P3m'>a8 Komi8m3n Uni8 K3<ia8an 

##################################################### &&&&&&&&&&&&&& ## NIP 9999999

LAPORAN PENERIMAAN DAN PENGGUNAAN A2AN"MATERIAL7 TENAGA KER!A7 DAN PERALATAN Dir348ora8 :  Sa8>an 43r5a :  P343r5aan :  Ta=>n An<<aran :  NO

I#TENAGA KER!A II# A2AN"MATERIAL III# ALAT

P$nan%%*n% !a/a3 KEA,LIAN UMLA, _P3n3rimaan^Tan<<a6 ^{3ni7 #a=an"}_Ma83ria6 ^{>m6a= ?an<}_;i83rima ^{>m6a= ?an<}_;i8o6a4 ^{>m6a= ?an<}_;ipa4ai 3ni7 >m6a=

1 2 $ * + . / 10 P36a47ana T>4an< #37i T>4an< #a8> T>4an< 4a?> Op3ra8or P3m'an8> Op3ra8or P343r5a 99999 9or< 9or< 9or< 9or< 9or< 9or< 9or< 9or< 9or< P3n<a@a7 P343r5aan (99999999999) NIP99999999 P36a47ana P343r5aan (99999999999) NIP99999999 95

LAPORAN 2ARIAN

,ari 43 - : 999999999

,ari"T<6 : 999999999

P343r5aan : 999999999

ITENAGA KERA II# A2AN III# ALAT IPEKERAAN ANG

DIKERAKAN ,ARI INI

KET KEA,LIAN UMLA, 3ni7 ?an< ;a8an< >m6a= ?an< ;i83rima >m6a= ?an< ;i8o6a4 >m6a= ?an< ;ipa4ai

Si7a 53ni7 >m6a= 3ni7 P343r5aan

1 2 $ * + . / 10 P36a47ana T>4an< #37i T>4an< #a8> T>4an< 4a?> Op3ra8or P3m'an8> Op3ra8or P343r5a 99999 9or< 9or< 9or< 9or< 9or< 9or< 9or< 9or<

 %UA%A I AM KERA II AM KERA E&EKTI&

P3n<a@a7 P343r5aan (99999999999) NIP99999999 P36a47ana P343r5aan (99999999999) NIP99999999 96

K$ma.*an P$$r.aan : &&&&&&&&&&&&

Min<<> 43 - : 99999999999999

NO URAIAN

TARGET ,ASIL PELAKSANAAN

KETERANGAN

OLUME #O#OT

#O#OT SD MINGGU

LALU

DALAM MINGGU INI #O#OT SD

MINGGU LALU OLUME PROSENTASE () #O#OT () 1 2 ! $  * + . / 10 P3n<a@a7 P343r5aan (9999999999999999) NIP999999999999 P36a47ana P343r5aan (9999999999999999) NIP999999999999 97

LAPORAN ULANAN

I PRESTASI &ISIK MINGGU I MINGGU II MINGGU III MINGGU I TOTAL REN%ANA ()

REALISASI () DEIASI ()

II TENAGA KERA MINGGU I MINGGU II MINGGU III MINGGU I TOTAL REN%ANA ()

REALISASI () DEIASI ()

III ALAT MINGGU I MINGGU II MINGGU III MINGGU I TOTAL

REN%ANA () REALISASI () DEIASI ()

I KEUANGAN MINGGU I MINGGU II MINGGU III MINGGU I TOTAL

REN%ANA () REALISASI () DEIASI ()

ERITA A6ARA PEMA8ARAN Nomor :  P343r5aan :  Lo4a7i P343r5aan :  Ta=>n An<<aran :  Tan<<a6 : 

Pa;a =ari ini 998an<<a6 999 '>6an 98a=>n 999 (9- 9 - 99) 4ami ?an< '3r8an;a 8an<an ;i 'a@a= ini :

1 Nama :  a'a8an : 

#3r;a7ar4an S>ra8 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'a<ai PI2AK KEDUA

#3r8in;a4 >n8>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<<a6 99999209 2 #3ri8a Aara S3ra= T3rima P343r5aan No : 999999999999999 8an<<a6 9 999209 ! #3ri8a Aara P3m3ri47aan P343r5aan No : 999999999999999 8an<<a6 9 999209 K3;>a '36a= pi=a4 836a= 73pa4a8 m3m'>a8 #3ri8a Aara P3m'a?aran ;3n<an p3rinian :

1 >m6a= ,ar<a P343r5aan  Rp99999999999

2 >m6a= an< T36a= Di'a?ar4an  Rp99999999999  ! >m6a= an< #36>m Di'a?ar4an  Rp99999999999

$ >m6a= an< ;imin8a4an  Rp99999999999

Po8on<an P3m'a?aran :

PPN  Rp99999999

PP= Pa7a6 221  Rp99999999 

 Rp99999999999   Rp99999999999

(Di+*'i, 4$n%an *r*f&&&&&&&&&&&&&&&&&&&&&&&&&&&&#

………….).

P3m'a?aran 83r73'>8 ;i'3'an4an 43pa;a DIPA (Daf8ar I7ian P36a47anaan An<<aran) Sa843r 99999999999  K3<ia8an 9999 999999999 (%on8o=: 01011!$21$02++!2111)

Pi=a4 K3;>a 73pa4a8 a8a7 5>m6a= p3m'a?aran 83r73'>8 ;i a8a7 ;i'a?ar4an 43pa;a #an4 99999 

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