FORMULIR PENGADUAN
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1. |
Identitas Warga / Pengadu / Pelapor |
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a. |
Nama |
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b. |
NIK / Identitas Lainnya |
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c. |
Alamat KTP |
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d. |
No. Telpon/ HP |
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e. |
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2. |
Isi Pengaduan / Laporan |
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3. |
Dokumen / Bukti Pendukung Yang Diserahkan (Bila Ada) |
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a. ……………………………………………………………………………………… |
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b. …………………………………………………………………………………….... |
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c. ……………………………………………………………………………………… |
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Petugas Penerima Pengaduan
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Pengadu/ Pelapor
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