KOMISI PEMILIHAN UMUM PROVINSI BANTEN

MODEL BA.HP-KWK V /

B E R I T A ACARA HASIL PENELIT IAN PERSYARATAN ADMINISTRASI DOKUMEN

PERSYARATAN PENCALONAN DAN PERSYARATAN CALON DALAM PEMILIHAN GUBERNUR DAN WAKIL GUBERNUR BANTEN

TAHUN 2017

P a d a h a r i i n i K a m i s t a n g g a l d u a p u l u h s e m b i l a n b u l a n S e p t e m b e r T a h u n d u a r i b u e n a m b e t a s b e r t e m p a t d i k a n t o r K o m i s i P e m i l i h a n U m u m P r o v i n s i B a n t e n J l . S y e c h N a w a w i A l b a n t a n i N o m o r 7 A K e l . B a n j a r A g u n g , C i p o c o k J a y a K o t a S e r a n g , K P U P r o v i n s i B a n t e n t e l a h m e l a k s a n a k a n p e n e l i t i a n p e r s y a r a t a n a d m i n i s t r a s i t e r h a d a p k e l e n g k a p a n d a n k e a b s a h a n d o k u m e n p e r s y a r a t a n p e n c a l o n a n d a n p e r s y a r a t a n c a l o n G u b e r n u r d a n W a k i l G u b e r n u r a t a s n a m a :

1 . C a l o n G u b e r n u r : Dr. H. Wahidin Hal im, M.Si

2 . C a l o n W a k i l G u b e r n u r : H. Andika Hazrumy, S.Sos,. M.AP

H a s i l p e n e l i t i a n p e r s y a r a t a n a d m i n i s t r a s i t e r h a d a p k e l e n g k a p a n d a n k e a b s a h a n d o k u m e n p e r s y a r a t a n p e n c a l o n a n d a n p e r s y a r a t a n c a l o n t e r s e b u t d i t u a n g k a n d a l a m t a b e l s e b a g a i m a n a t e r l a m p i r .

D e m i k i a n B e r i t a A c a r a d i b u a t 2 ( d u a ) r a n g k a p , m a s i n g - m a s i n g r a n g k a p d i t a n d a t a n g a n i o l e h K e t u a d a n A n g g o t a K P U P r o v i n s i B a n t e n . B e r i t a A c a r a d i s u s u n m a s i n g - m a s i n g : 1 . 1 ( s a t u ) r a n g k a p d i s a m p a i k a n k e p a d a p a s a n g a n c a l o n ; 2 . 1 ( s a t u ) r a n g k a p u n t u k a r s i p ;

KOMIS I PEMILIHAN UMUM PROVINSI BANTEN

NO. NAMA JABATAN TANDA TANGAN

1 . A G U S S U P R I Y A T N A K e t u a

2 . S Y A E F U L B A H R I A n g g o t a ^ ^ ^ ^ 3 . A G U S S U P A D M O A n g g o t a

4 . D I D I H M . S U D I A n g g o t a

5 . E N A N N A D I A A n g g o t a

LAMPIRAN M O D E L BA.HP-KWK

LAMPIRAN BERITA ACARA PENELITIAN PERSYARATAN ADMINISTRASI DOKUMEN PERSYARATAN PENCALONAN DAN PERSYARATAN CALONDALAM PEMILIHAN GUBERNUR DAN WAKIL GUBERNUR/BUPATI DAN

WAKIL BUPATI / WALIKOTA DAN WAKIL WALIKOTA *)

H a s i l p e n e l i t i a n p e r s y a r a t a n a d m i n i s t r a s i d o k u m e n p e r s y a r a t a n p e n c a l o n a n d a n p e r s y a r a t a n c a l o n d a l a m p e m i l i h a n G u b e r n u r d a n W a k i l G u b e r n u r B a n t e n a t a s :

N a m a B a k a l C a l o n G u b e r n u r :

Dr. H. WAHIDIN HALIM, M.Si.

N a m a B a k a l C a l o n W a k i l G u b e r n u r :

H. ANDIKA HAZRUMY, S.Sos.,M.Si. s e b a g a i b e r i k u t :

A. SYARAT PENCALONAN

HASIL PENELITIAN KELENGKAPAN DAN KEABSAHAN DOKUMEN K E T NO J E N I S DOKUMEN ADA TIDAK MEMENUHI BELUM

ADA SYARAT MEMENUHI SYARAT

CALON D A R I PARTAI P O L I T I K 1 M o d e l B . 4 K W K - P a r p o l 2 K e p u t u s a n t e n t a n g K e p e n g u r u s a n P a r t a i P o l i t i k

s e s u a i t i n g k a t a n n y a d a l a m h a l t e r j a d i p e r u b a h a n k e p e n g u r u s a n s e t e l a h p e n d a f t a r a n

• \

CALON DARI P E R S E O R A N G A N 1 M o d e l B . 3 K W K - P e r s e o r a n g a n

2

B. SYARAT CALON 1 . C A L O N G U B E R N U R :

NO J E N I S DOKUMEN HASIL P E N E L I T I A N K E L E N G K A P A N DAN KEABSAHAN DOKUMEN

K E T NO J E N I S DOKUMEN

ADA T I D A K ADA MEMENUHI S Y A R A T

B E L U M MEMENUHI

S Y A R A T 1 . M o d e l B B . 1 K W K V 2 . M o d e l B B . 2 K W K 3 . S u r a t k e t e r a n g a n k e m a m p u a n j a s m a n i d a n r o h a n i s e r t a

b e b a s p e n y a l a h g u n a a n n a r k o t i k a J

y J

y

H a s i l P e m e r i k s a a n T i m K e s e h a t a n t g l 2 8 S e p 2 0 1 6

4 . K e p u t u s a n p e m b e r h e n t i a n d a r i p e j a b a t b e r w e n a n g a p a b i l a C a l o n a d a l a h A n g g o t a K P U , K P U P r o v i n s i / K I P A c e h , K P U / K I P K a b u p a t e n / K o t a , B a w a s l u , B a w a s l u P r o v i n s i , P a n w a s K a b u p a t e n / K o t a .

5 . S u r a t k e t e r a n g a n t i d a k p e r n a h s e b a g a i t e r p i d a n a b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p d a r i p e n g a d i l a n n e g e r i y a n g w i l a y a h h u k u m n y a m e l i p u t i t e m p a t t i n g g a l c a l o n

6 . S u r a t k e t e r a n g a n d i p i d a n a k a r e n a k e a l p a a n r i n g a n {culpa leuis) a t a u a l a s a n p o l i t i k b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p e r o l e h k e k u a t a n h u k u m t e t a p d a r i p e n g a d i l a n n e g e r i y a n g m e n j a t u h k a n p u t u s a n , b a g i b a k a l c a l o n y a n g p e r n a h d i p i d a n a p e n j a r a k a r e n a k e a l p a a n r i n g a n {culpa lews) a t a u a l a s a n p o l i t i k

K e a l p a a n R i n g a n / A l a s a n P o l i t i k * )

7 . B a g i B a k a l C a l o n d e n g a n s t a t u s t e r p i d a n a y a n g t i d a k m e n j a l a n i p i d a n a d a l a m p e n j a r a :

7 .

a . B u k t i t e l a h m e n g e m u k a k a n k e p a d a p u b l i k s e c a r a t e r b u k a d a n j u j u r p a d a s u r a t k a b a r l o k a l a t a u n a s i o n a l

7 .

b . S a l i n a n p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p

7 .

c . s u r a t k e t e r a n g a n d a r i k e j a k s a a n m e n g e n a i t e r p i d a n a t i d a k m e n j a l a n i p i d a n a d a l a m p e n j a r a

3

8 . S a l i n a n p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p , d a l a m h a l b a k a l C a l o n a d a l a h M a n t a n T e r p i d a n a y a n g t e l a h s e l e s a i m e n j a l a n i m a s a p i d a n a n y a p a l i n g s i n g k a t 5 ( l i m a ) t a h u n s e b e l u m j a d w a l p e n d a f t a r a n d a n b u k a n m a n t a n t e r p i d a n a b a n d a r n a r k o b a a t a u k e j a h a t a n s e k s u a l t e r h a d a p a n a k

9 . D a l a m h a l b a k a l C a l o n a d a l a h M a n t a n T e r p i d a n a y a n g t e l a h s e l e s a i m e n j a l a n i p i d a n a p e n j a r a t e t a p i b e l u m m e l a m p a u i p a l i n g s i n g k a t 5 ( l i m a ) t a h u n s e b e l u m j a d w a l p e n d a f t a r a n d a n b u k a n m a n t a n t e r p i d a n a b a n d a r n a r k o b a d a n k e j a h a t a n s e k s u a l t e r h a d a p a n a k : a . B u k t i t e l a h m e n g e m u k a k a n k e p a d a p u b l i k s e c a r a

t e r b u k a d a n j u j u r p a d a s u r a t k a b a r l o k a l a t a u n a s i o n a l

b . s u r a t k e t e r a n g a n y a n g m e n y a t a k a n b a h w a B a k a l C a l o n y a n g b e r s a n g k u t a n b u k a n s e b a g a i p e l a k u k e j a h a t a n y a n g b e r u l a n g d a r i K e p o l i s i a n s e s u a i t i n g k a t a n n y a .

c . s u r a t k e t e r a n g a n t e l a h s e l e s a i m e n j a l a n i p i d a n a p e n j a r a d a r i k e p a l a l e m b a g a p e r m a s y a r a k a t a n

d . s u r a t k e t e r a n g a n t e l a h s e l e s a i m e n j a l a n i p e m b e b a s a n b e r s y a r a t , c u t i b e r s y a r a t a t a u c u t i m e n j e l a n g b e b a s d a r i k e p a l a b a d a n p e m a s y a r a k a t a n , d a l a m h a l B a k a l C a l o n m e n d a p a t p e m b e b a s a n b e r s y a r a t , c u t i b e r s y a r a t a t a u c u t i m e n j e l a n g b e b a s

e . p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p

1 0 . S u r a t k e t e r a n g a n d a r i p e n g a d i l a n n e g e r i y a n g w i l a y a h h u k u m n y a m e l i p u t i t e m p a t t i n g g a l C a l o n y a n g m e n y a t a k a n b a h w a : a . t i d a k s e d a n g d i c a b u t h a k p i l i h n y a b e r d a s a r k a n V V

p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p u n y a i k e k u a t a n h u k u m t e t a p

b . t i d a k s e d a n g m e m i l i k i t a n g g u n g a n h u t a n g s e c a r a p e r s e o r a n g a n d a n / a t a u s e c a r a b a d a n h u k u m y a n g m e n j a d i t a n g g u n g j a w a b n y a y a n g m e r u g i k a n k e u a n g a n

V

n e g a r a 1 1 . S u r a t k e t e r a n g a n c a t a t a n k e p o l i s i a n y a n g m e n e r a n g k a n

B a k a l C a l o n p e r n a h / t i d a k p e r n a h m e l a k u k a n p e r b u a t a n t e r c e l a d a r i K e p o l i s i a n s e s u a i t i n g k a t a n n y a

V

1 2 . S u r a t t a n d a t e r i m a p e n y e r a h a n l a p o r a n h a r t a k e k a y a a n p e n y e l e n g g a r a n e g a r a d a r i K o m i s i P e m b e r a n t a s a n K o r u p s i

T T

T T 1 3 .

1 4 .

S u r a t k e t e r a n g a n t i d a k s e d a n g d i n y a t a k a n p a i l i t b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p u n y a i k e k u a t a n h u k u m t e t a p d a r i p e n g a d i l a n n i a g a a t a u p e n g a d i l a n t i n g g i y a n g w i l a y a h h u k u m n y a m e l i p u t i t e m p a t t i n g g a l c a l o n D o k u m e n y a n g d i k e l u a r k a n o l e h K a n t o r P e l a y a n a n P a j a k t e m p a t c a l o n y a n g b e r s a n g k u t a n t e r d a f t a r s e b a g a i w a j i b

a . F o t o k o p i k a r t u N o m o r P o k o k W a j i b P a j a k ( N P W P ) a t a s n a m a c a l o n

b . T a n d a t e r i m a p e n y a m p a i a n S u r a t P e m b e r i t a h u a n T a h u n a n P a j a k P e n g h a s i l a n W a j i b P a j a k O r a n g P r i b a d i a t a s n a m a b a k a l c a l o n , u n t u k m a s a 5 ( l i m a ) t a h u n t e r a k h i r a t a u s e j a k c a l o n m e n j a d i w a j i b p a j a k

V V

c . T a n d a b u k t i t i d a k m e m p u n y a i t u n g g a k a n p a j a k 1 5 . S u r a t k e p u t u s a n p e m b e r h e n t i a n s e b a g a i p e n j a b a t

G u b e r n u r , p e n j a b a t B u p a t i a t a u p e n j a b a t W a l i k o t a b a g i c a l o n y a n g b e r s t a t u s s e b a g a i p e n j a b a t G u b e r n u r , p e n j a b a t B u p a t i a t a u p e n j a b a t W a l i k o t a

1 6 . F o t o k o p i K a r t u T a n d a P e n d u d u k E l e k t r o n i k V 1 7 . F o t o k o p i I j a z a h / S u r a t T a n d a T a m a t B e l a j a r ( S T T B ) , y a n g

t e l a h d i l e g a l i s a s i o l e h i n s t a n s i y a n g b e r w e n a n g 1 8 . N a s k a h v i s i , m i s i d a n p r o g r a m P a s a n g a n C a l o n m e n g a c u

p a d a R e n c a n a P e m b a n g u n a n J a n g k a P a n j a n g ( R P J P ) D a e r a h y a n g d i t a n d a t a n g a n i P a s a n g a n C a l o n

V

1 9 . D a f t a r n a m a T i m K a m p a n y e t i n g k a t p r o v i n s i , k a b u p a t e n / k o t a , d a n / a t a u k e c a m a t a n

2 0 . a . P a s F o t o B e r w a r n a u k u r a n 4 x 6 c m s e b a n y a k 4 l e m b a r

T T

b . P a s F o t o H i t a m P u t i h u k u r a n 4 x 6 c m s e b a n y a k 4 l e m b a r

c . F o t o c a l o n u k u r a n 1 0 . 2 c m x 1 5 . 2 c m ( 4 R ) s e b a n y a k 2 l e m b a r

T d . S o f t c o p y F o t o s e b a g a i m a n a h u r u f a , h u r u f b , d a n h u r u f c

Keterangan : *) P i l i h s a l a h s a t u .

5

2 . C A L O N W A K I L G U B E R N U R :

NO J E N I S DOKUMEN H A S I L P E N E L I T I A N K E L E N G K A P A N DAN KEABSAHAN DOKUMEN

K E T NO J E N I S DOKUMEN

ADA T I D A K ADA MEMENUHI S Y A R A T

B E L U M MEMENUHI

S Y A R A T 1 . M o d e l B B . 1 K W K V V 2 . M o d e l B B . 2 K W K V V 3 . S u r a t k e t e r a n g a n k e m a m p u a n j a s m a n i d a n r o h a n i s e r t a

b e b a s p e n y a l a h g u n a a n n a r k o t i k a H a s i l P e m e r i k s a a n T i m K e s e h a t a n t g l 2 8 S e p 2 0 1 6

4 . K e p u t u s a n p e m b e r h e n t i a n d a r i p e j a b a t b e r w e n a n g a p a b i l a C a l o n a d a l a h A n g g o t a K P U , K P U P r o v i n s i / K I P A c e h , K P U / K I P K a b u p a t e n / K o t a , B a w a s l u , B a w a s l u P r o v i n s i , P a n w a s K a b u p a t e n / K o t a .

- -

5 . S u r a t k e t e r a n g a n t i d a k p e r n a h s e b a g a i t e r p i d a n a b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p d a r i p e n g a d i l a n n e g e r i y a n g w i l a y a h h u k u m n y a m e l i p u t i t e m p a t t i n g g a l c a l o n

6 . S u r a t k e t e r a n g a n d i p i d a n a k a r e n a k e a l p a a n r i n g a n {culpa levis) a t a u a l a s a n p o l i t i k b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p e r o l e h k e k u a t a n h u k u m t e t a p d a r i p e n g a d i l a n n e g e r i y a n g m e n j a t u h k a n p u t u s a n , b a g i b a k a l c a l o n y a n g p e r n a h d i p i d a n a p e n j a r a k a r e n a k e a l p a a n r i n g a n {culpa levis) a t a u a l a s a n p o l i t i k

- - K e a l p a a n R i n g a n / A l a s a n P o l i t i k * )

7 . B a g i B a k a l C a l o n d e n g a n s t a t u s t e r p i d a n a y a n g t i d a k m e n j a l a n i p i d a n a d a l a m p e n j a r a :

7 .

a . B u k t i t e l a h m e n g e m u k a k a n k e p a d a p u b l i k s e c a r a t e r b u k a d a n j u j u r p a d a s u r a t k a b a r l o k a l a t a u n a s i o n a l

_ _

7 .

b . S a l i n a n p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p

7 .

c . s u r a t k e t e r a n g a n d a r i k e j a k s a a n m e n g e n a i t e r p i d a n a t i d a k m e n j a l a n i p i d a n a d a l a m p e n j a r a

8 . S a l i n a n p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p , d a l a m h a l b a k a l C a l o n a d a l a h M a n t a n T e r p i d a n a y a n g t e l a h s e l e s a i m e n j a l a n i m a s a p i d a n a n y a p a l i n g s i n g k a t 5 ( l i m a ) t a h u n s e b e l u m j a d w a l p e n d a f t a r a n d a n b u k a n m a n t a n t e r p i d a n a b a n d a r n a r k o b a a t a u k e j a h a t a n s e k s u a l t e r h a d a p a n a k

6

9 . D a l a m h a l b a k a l C a l o n a d a l a h M a n t a n T e r p i d a n a y a n g t e l a h s e l e s a i m e n j a l a n i p i d a n a p e n j a r a t e t a p i b e l u m m e l a m p a u i p a l i n g s i n g k a t 5 ( l i m a ) t a h u n s e b e l u m j a d w a l p e n d a f t a r a n d a n b u k a n m a n t a n t e r p i d a n a b a n d a r n a r k o b a d a n k e j a h a t a n s e k s u a l t e r h a d a p a n a k : a . B u k t i t e l a h m e n g e m u k a k a n k e p a d a p u b l i k s e c a r a

t e r b u k a d a n j u j u r p a d a s u r a t k a b a r l o k a l a t a u n a s i o n a l s u r a t k e t e r a n g a n y a n g m e n y a t a k a n b a h w a B a k a l C a l o n y a n g b e r s a n g k u t a n b u k a n s e b a g a i p e l a k u k e j a h a t a n y a n g b e r u l a n g d a r i K e p o l i s i a n s e s u a i t i n g k a t a n n y a .

c . s u r a t k e t e r a n g a n t e l a h s e l e s a i m e n j a l a n i p i d a n a p e n j a r a d a r i k e p a l a l e m b a g a p e r m a s y a r a k a t a n s u r a t k e t e r a n g a n t e l a h s e l e s a i m e n j a l a n i p e m b e b a s a n b e r s y a r a t , c u t i b e r s y a r a t a t a u c u t i m e n j e l a n g b e b a s d a r i k e p a l a b a d a n p e m a s y a r a k a t a n , d a l a m h a l B a k a l C a l o n m e n d a p a t p e m b e b a s a n b e r s y a r a t , c u t i b e r s y a r a t a t a u c u t i m e n j e l a n g b e b a s

1 0 .

e . p u t u s a n p e n g a d i l a n y a n g t e l a h b e r k e k u a t a n h u k u m t e t a p

S u r a t k e t e r a n g a n d a r i p e n g a d i l a n n e g e r i y a n g w i l a y a h h u k u m n y a m e l i p u t i t e m p a t t i n g g a l C a l o n y a n g

a . t i d a k s e d a n g d i c a b u t h a k p i l i h n y a b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p u n y a i k e k u a t a n h u k u m t e t a p

b . t i d a k s e d a n g m e m i l i k i t a n g g u n g a n h u t a n g s e c a r a p e r s e o r a n g a n d a n / a t a u s e c a r a b a d a n h u k u m y a n g m e n j a d i t a n g g u n g j a w a b n y a y a n g m e r u g i k a n k e u a n g a n n e g a r a

V S e d a n g d a l a m p r o s e s

1 1 . S u r a t k e t e r a n g a n c a t a t a n k e p o l i s i a n y a n g m e n e r a n g k a n B a k a l C a l o n p e r n a h / t i d a k p e r n a h m e l a k u k a n p e r b u a t a n t e r c e l a d a r i K e p o l i s i a n s e s u a i t i n g k a t a n n y a

V

1 2 . S u r a t t a n d a t e r i m a p e n y e r a h a n l a p o r a n h a r t a k e k a y a a n p e n y e l e n g g a r a n e g a r a d a r i K o m i s i P e m b e r a n t a s a n K o r u p s i

V V 1 3 . S u r a t k e t e r a n g a n t i d a k s e d a n g d i n y a t a k a n p a i l i t

b e r d a s a r k a n p u t u s a n p e n g a d i l a n y a n g t e l a h m e m p u n y a i k e k u a t a n h u k u m t e t a p d a r i p e n g a d i l a n n i a g a a t a u p e n g a d i l a n t i n g g i y a n g w i l a y a h h u k u m n y a m e l i p u t i t e m p a t t i n g g a l c a l o n

V

7

1 4 . D o k u m e n y a n g d i k e l u a r k a n o l e h K a n t o r P e l a y a n a n P a j a k t e m p a t c a l o n y a n g b e r s a n g k u t a n t e r d a f t a r s e b a g a i w a j i b p a j a k : a . F o t o k o p i k a r t u N o m o r P o k o k W a j i b P a j a k ( N P W P ) a t a s

n a m a c a l o n T a n d a t e r i m a p e n y a m p a i a n S u r a t P e m b e r i t a h u a n T a h u n a n P a j a k P e n g h a s i l a n W a j i b P a j a k O r a n g P r i b a d i a t a s n a m a b a k a l c a l o n , u n t u k m a s a 5 ( l i m a ) t a h u n t e r a k h i r a t a u s e j a k c a l o n m e n j a d i w a j i b p a j a k

S e d a n g d a l a m p r o s e s

c . T a n d a b u k t i t i d a k m e m p u n y a i t u n g g a k a n p a j a k S e d a n g d a l a m p r o s e s

1 5 . S u r a t k e p u t u s a n p e m b e r h e n t i a n s e b a g a i p e n j a b a t G u b e r n u r , p e n j a b a t B u p a t i a t a u p e n j a b a t W a l i k o t a b a g i c a l o n y a n g b e r s t a t u s s e b a g a i p e n j a b a t G u b e r n u r , p e n j a b a t B u p a t i a t a u p e n j a b a t W a l i k o t a

1 6 . F o t o k o p i K a r t u T a n d a P e n d u d u k E l e k t r o n i k F o t o k o p i I j a z a h / S u r a t T a n d a T a m a t B e l a j a r ( S T T B ) , y a n g t e l a h d i l e g a l i s a s i o l e h i n s t a n s i y a n g b e r w e n a n g

1 8 . N a s k a h v i s i , m i s i d a n p r o g r a m P a s a n g a n C a l o n m e n g a c u p a d a R e n c a n a P e m b a n g u n a n J a n g k a P a n j a n g ( R P J P ) D a e r a h y a n g d i t a n d a t a n g a n i P a s a n g a n C a l o n

1 9 . D a f t a r n a m a T i m K a m p a n y e t i n g k a t p r o v i n s i , k a b u p a t e n / k o t a , d a n / a t a u k e c a m a t a n

2 0 . F o t o T e r b a r u a . P a s F o t o B e r w a r n a u k u r a n 4 x 6 c m s e b a n y a k 4 l e m b a r b . P a s F o t o H i t a m P u t i h u k u r a n 4 x 6 c m s e b a n y a k 4

l e m b a r c . F o t o c a l o n u k u r a n 1 0 . 2 c m x 1 5 . 2 c m ( 4 R ) s e b a n y a k 2

l e m b a r d . S o f t c o p y F o t o s e b a g a i m a n a h u r u f a , h u r u f b , d a n

h u r u f c Keterangan : *) P i l i h s a l a h s a t u .

8

S e r a n g , tft S e p t e m b e r 2 0 1 6

K P U Provinsi Banten

NO NAMA JABATAN TANDA TANGAN

1 . A G U S S U P R I Y A T N A K e t u a

2 . S Y A E F U L B A H R I A n g g o t a

3 . A G U S S U P A D M O A n g g o t a

4 . D I D I H M . S U D I A n g g o t a

5 . E N A N N A D I A A n g g o t a 4 ^