M O D E L T T . l - K W K > —"

TANDA TER IMA PENDAFTARAN PASANGAN CALON GUBERNUR DAN WAKIL GUBERNUR BANTEN

B a h w a p a d a h a r i J u m ' a t t a n g g a l Dua puluh tiga b u l a n September t a h u n

2 0 1 6 , t e l a h d i t e r i m a 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 . N a m a C a l o n G u b e r n u r :

H. RANO KARNO, S.IP.

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

H. EMBAY MULYA S Y A R I E F

y a n g b e r i s i j e n i s d o k u m e n d a l a m b e n t u k hardfile d a n softfile y a n g a k a n d i p e r i k s a d a n a k a n d i c a t a t d a l a m L a m p i r a n T a n d a T e r i m a P e n d a f t a r a n P a s a n g 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 s e b a g a i m a n a t e r l a m p i r .

Y a n g M e n y e r a h k a n

AGUS SETIAWAN

LAMPIRAN M O D E L T T . l - K W K

LAMPIRAN TANDA TER IMA PENDAFTARAN BAKAL PASANGAN CALON GUBERNUR DAN WAKIL GUBERNUR BANTEN

1 . I d e n t i t a s C a l o n G u b e r n u r :

N a m a : H . R A N O K A R N O , S . I P .

A l a m a t : J l . K a r a n g A s r i V I I / 1 A R T . 0 8 R W . 0 9 K e l . L e b a k B u l u s K e c . C i l a n d a k J a k a r t a S e l a t a n

N o m o r T e l p :

2 . I d e n t i t a s C a l o n W a k i l G u b e r n u r :

N a m a : H . E M B A Y M U L Y A S Y A R I E F

A l a m a t : J l . J i w a n t a k a 1 N o . 9 P e k a r u n g a n R T . 0 0 1 R W . 0 0 1 K e l . K a g u n g a n K e c . S e r a n g P r o v . B a n t e n

N o m o r T e l p :

3 . W a k t u P e n y e r a h a n D o k u m e n P e n d a f t a r a n :

H a r i : J u m ' a t

T a n g g a l : 2 3 S e p t e m b e r 2 0 1 6

W a k t u : 1 5 : 1 5

4 . P a r t a i P o l i t i k a t a u G a b u n g a n P a r t a i P o l i t i k ** ) p e n g u s u l :

N O P A R T A I P O L I T I K

A L A M A T K A N T O R

1—V I \ T T 7 a » •

D E W A N P I M P I N A N

P A R T A I P O L I T I K

N O M O R T E L E P O N K A N T O R D E W A N

P I M P I N A N P A R T A I

P O L I T I K

N O M O R K E P U T U S A N P I M P I N A N P A R T A I P O L I T I K

T I N G K A T P U S A T D A N / A T A U K E P U T U S A N P I M P I N A N

P A R T A I P O L I T I K T I N G K A T P R O V I N S I 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 1""* / — V T T FTVT T T

P O L I T I K

T A N G G A L K E P U T U S A N

P I M P I N A N P A R T A I P O L I T I K T I N G K A T P U S A T

D A N / A T A U T r T—\ T—^ T T ATA T T f^S A ~A T

K E P U T U S A N P I M P I N A N

P A R T A I P O L I T I K T I N G K A T

T—V 1 \ X T T Tfc T A-A X

P R O V I N S I 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

N O M O R K E P U T U S A N

P I M P I N A N P A R T A I

P O L I T I K T I N G K A T

P U S A T T E N T A N G

P E R S E T U J U A N B A K A L

P A S A N G A N C A L O N

T A N G G A L K E P U T U S A N

P I M P I N A N P A R T A I

P O L I T I K T I N G K A T

P U S A T T E N T A N G

P E R S E T U J U A N B A K A L P A S A N G A N

C A L O N

1 . P D I P e r j u a n g a n

J l . L e n t e n g A g u n g N o . 9 9 J a k s e l

"K K T T T T f \ C~ A T T 1 1 /"\ 1 ATA 1

- M . H H . 0 5 . A H . 1 1 . 0 1 T a h u n 2 0 1 5

- 2 0 - A / K P T S - D P D / D P P / V / 2 0 1 5

- 7 M e i 2 0 1 5

- 1 2 M e i 2 0 1 5

I S T I M E W A 2 0 / 9 / 2 0 1 6

2 . P a r t a i P e r s a t u a n P e m b a n g u n a n

J l . D i p e n e g o r o N o . 6 0 J a k a r t a

n o 1 0 2 1 -8 3 7 9 5 9 5 3

A K T T T T r\Ci A TJT 11 A 1 T A U T T M

- M . r i r i - O o . A H . 1 1 . 0 1 l A H U I N 2 0 1 6

- 0 3 5 / S K / D P P / W / V I I I / 2 0 1 6

O T A . - .».^1 O A K - 2 / A p r i l 2 0 1 6

- 1 1 A g u s t u s 2 0 1 6

1 1 7 / O l / / 1 0 o n /

1 1 / / S K / D P P / C / I X / 2 0 1 6

i n / o / o n 1 ^

1 9 / 9 / 2 0 1 6

3 . P a r t a i N a s d e m J l . R . P . S o e r o s o N o . 4 4 G o n d a n g d i a L a m a J a k a r t a

0 2 1 -3 9 2 9 8 0 1

- M . H H - 0 3 . A H . 1 1 . 0 1 T a h u n 2 0 1 3

- 1 0 3 - S K / D P P -N a s D e m / I V / 2 0 1 6

- 6 M a r e t 2 0 1 3 - 6 A p r i l 2 0 1 6

1 3 2 - K p t s / D P P - N a s d e m / I X / 2 0 1 6

2 1 / 9 / 2 0 1 6

SYARAT PENCALONAN

N O J E N I S D O K U M E N

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 D A N K E A B S A H A N D O K U M E N K E T

N O J E N I S D O K U M E N A D A T I D A K A D A M E M E N U H I S Y A R A T

T I D A K M E M E N U H I

S Y A R A T CALON DARI PARTAI POLITIK

1 M o d e l B K W K - P a r p o l V 2 M o d e l B . 1 K W K - P a r p o l 3 p a r p o l 3 M o d e l B . 2 K W K - P a r p o l V 4 M o d e l B . 3 K W K - P a r p o l V 5 M o d e l B . 4 K W K - P a r p o l V ( k e a b s a h a n

d o k u m e n d i t e l i t i p a d a m a s a v e r i f i k a s i )

6 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

V

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

CALON DARI PERSEORANGAN 1 M o d e l B A . 7 - K W K P e r s e o r a n g a n / M o d e l B A . 8 -

K W K P e r s e o r a n g a n 2 M o d e l B K W K - P e r s e o r a n g a n 3 M o d e l B . 3 . K W K - P e r s e o r a n g a n ( k e a b s a h a n

d o k u m e n d i t e l i t i p a d a m a s a v e r i f i k a s i )

B. SYARAT CALON

1. CALON GUBERNUR

NO JENIS DOKUMEN HASIL PEMERIKSAAN

KELENGKAPAN DOKUMEN KETERANGAN NO JENIS DOKUMEN ADA TIDAK ADA

KETERANGAN

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 V 3 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 P U 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 .

4 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

V

5 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 ( c u l p a l e v i s ) 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 ( c u l p a l e v i s ) 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 * )

6 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 : 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 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 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 7 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

8 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 & \ C P \ t p n n v 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 - -9 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 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

1 0 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 n p r n a h / t i d a k n e r n a b m e l a k n k a n n e r b u a t a n t e r c e l a d a r i K e n 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 1 S u r a t t a n d a t e r i m a n e n v e r a h a n l a n o r a n h a r t a k e k a v a a n n e n v e l e n ^ c a r a n e e a r a W_J I X X C t L L C l l l V U C l L l / l 1 1 1 1 C I L / V l 1. y V^X C L L 1 C U 1 I C I L / V a i C U X XXGX-X L U I V l I V l l V C I C U X p C l l V O O O

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 1 2 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

1 3 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 h T q n H a t p r i m a n p n v a m n q i f i n S l i i r ^ t PpTTihpnt£ihn£in T a h n n a n P r n f l W P p n p h p i s i l f i n U. 1 C U l t l d L C I 1 1 l i d . U C l l y C U 1 1 U C U C U 1 C x L l l C l L 1 C X l l L f C l l L C U . l L 4 . C L i l 1 C U 1 L 4 1 1 C U 1 1 C L J C U V 1 V / l l g i l C x O l l C U X

W h i i h P p i p i k " Oranfy P r i h f i H i a t a s n a m a h a l c a l p a l o n u n t u W m a s a 5 f l i m a ) t a h u n V V C t l 1 U 1 C U C U V C I C U l g 1 X 1 L / C L C 1 1 C L L C X O X X C U X X C X U C U V C U C C U L / X X , L 4 X X L L 4 X V X X X C X O C X kJ 1XXX X X C X I I C U 1 U i i

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

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 V D a l a m P r o s e s 1 4 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 5 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 6 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 B e l u m d i l e g a l i s i r

1 7 N a s l c a h v i s i m i s i d a n n r o e r a m P a s a n p a n C a l o n m e n e a c u D a d a R e n c a n a X ™ ( A O I Y C 1 X X V X O l j X X X X VXX M U 1 X k—/ A CL A XXX XX X I A V J I X 1 X g l X A X W i A A V l X l l l v l l w k l v XX 1 J XX XX XX X W l l V X A l l M

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 8 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 X J C J X ' X / 9 1

k e c a m a t a n V

1 9 F o t o T e r b a r u 1 9 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 V

1 9

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 V

1 9

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 V

1 9

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

CALON WAKIL GUBERNUR

NO JENIS DOKUMEN HASIL PEMERIKSAAN

KELENGKAPAN DOKUMEN KETERANGAN NO JENIS DOKUMEN ADA TIDAK ADA

KETERANGAN

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 V 3 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 P U 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 .

4 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

5 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 ( c u l p a l e v i s ) 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 ( c u l p a l e v i s ) 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 * )

6 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 : d. 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 e. 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

f. 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

7 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

8 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 : f. 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 g. 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 .

- -

h . 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

- -

i . 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

_ _

j . 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 - -9 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 : c. 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 V

d. 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 D a l a m P r o s e s P e n g a j u a n

1 0 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 1 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

1 2 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 D a l a m P r o s e s P e n g a j u a n

1 3 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 : d . 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 V

e. 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

f. 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 V D a l a m P r o s e s 1 4 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 5 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 6 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 V

1 7 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 8 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

V

1 9 F o t o T e r b a r u e . 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 f . 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 g . 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 V h . 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 .