170801125430Perki No.1 Tahun 2013

!" "
#
$$%
' "
(
&"
' "
)
' "

&
(
"
*
&"
#
)

' "
"

$ $
' "

!" "

(
(
+ (

"
(

+
!" "

&
- (
#
$ $
.

!
!" " /

(

' "
"

'
,
&"
)

#

#
!
' "
,

- (
#

'
.

$$%
,
$$% !"
!" " %
!" "
' "
"
#
!
!"

!
"
*

#
$ $
"

0

1
' "

"
"

(

2
(

2

"

.
(

(

(

.
&

' "
(

"
(
.
(" "
(
(

(

(

3

(

" (

3
(

"

3
(

(

2

(

(
3

3

2

2
)
.
' "

' "

3
" "

' "

2
( "

' "
3

"
'0

(

(

(

"
4

(
' "
( 3
"

3
3
2

(

'0
'0

( 3

(

(

2
3

" "

"

(

' "
" "

3

"

" " ' "

)
' "

" "
"
" "
&"
' "

3
(
)
" "
3

2

(

" "
3

/

(

3

3
(

(

0"

.

5
( 3
( 3

2

" "

(

(
)

' "
" "
(

3
' "
&"

' "

%

#

" "
#

)
" "

.
'0

.
&"
6

' "
( "

53
(

' "

3
"
3

( 3
(

(

(

)

(

(

' "

(

(

"

&"

' "
$

(
(
&"
' "

' "
"7

)
"
&"
&"
(

2

"

"
(

(

"
(

(

' "
"
"
' "
' "
&
&"
' "
( "
(
)

(
&"
(

2&"
+

' "

+

(
"

"

"

(

&"
"

"
&"
&
4

"
(
&"
"

"

(
"

&"
"

(
)

"

&
' "

)

&"

' "
" "

+

(
3

"

(
"

6 5
(

"

&"

3

% )
(
"

(
+ (

(

)
(

' "

5+

(

"

2

"
.

(
3

&"

(
("

/

' "
3

3

"
(

(

' "

&"
(

"

(

' "
"

(
3

' "

(

' "
3

" "

(

"

(
"
"

3
(
(
' "

&"

(

"

(

(

" "
( "

3
3

8

(

(
(
( (

" "

" "
(

1
(

" "

3
3
7

(
( "

3

" "

(

" "

3

(

+

(

+

(
&"

0
(

(
( "

(
(

' "
(
(

(

(
(
&"

&
( "

(

" "
' "

(

(
4 &
&"

3

(
3

(

& (

&

' "

)
(

' "

(
" "

&"

' "

(

1
(

(

"

(

'0*

" "

(

3

(
3

3

(
3
"

'0

$

(

'0

!
&"

' "

)

' "

.
&"
' "
&"
)

' "

(
0

"7

' "
' "
2 "
&"

&

' "

.
2&"
.

' "

.
&"

(

)
( "7

&
)

(
(

"7

2&"
' "
2 "

"

4 0

&"

' "

"7

)
( "7
&"

' "

.
(

2 "

"

' "
"

&"

' "

' "
' "
&"
"7
&"
(

"7
)

(

&"

' "

' "

"7

&"

(

(

)

3
' "

&

(

' "
)

2&"
)

&
(
' "

(

&"

' "

' "
2&"

(

#
0
&"
"
&"
9

)

' "

' "
&"
' "
' "

.
(
"
3

#

" "
(

& (

&

&"

' "

$% & ' ()
( * +

" "

3

" "
" "
" "

3

,
" "

"

(

&"

' "

"

+

"
" "
(

3

" "
" "

" "

"

( (
+

" "

3

(

:"

" "
'

1

" " 1
(

2

*

(*

4

" "

("

" "

2

3
(

+ ;

3
(

" "

" "
*
&"
' "
" "

"

"

1
"

3
(

" " *
#

" "

"
#

" "

+

3

"

+

*
#

( (
( (

" "
" "
#

(
#

" "
" "
3
(
" "
*
#
(
" "
(
" "
" "
*
2
#
"
3
&"
' "

4

,

" "

#
" " *

"

" "

3

(

3 *
"

.

" "
"
"
" "

(

" "
( (
" "
"
"

" "

"

#
" "

"

" "

3

"
(

" "

"
(

" "
'

(
(

3

"

(

" "

1
" "
" " "( &

1
#

("
(

'

"

" "

*
"

;
5
' "
)
(

+
" "
" " "( &
" "
"
(
.
" "
"
(
2(
3
(

" "
(
(
(

+

;

(
" "

.
.

(

- (

;

#

(
" (" "
1

" "
" "

"
.

"
.

!

*
1

*

2

(

" "

"

'0*
(
2(

(
"

3
3

(

*

(

0

" "
" "
" "

(
(

3

"
" "

)

' "
"

(

3

+

"

.

(

"

0

(

(

" "

&"

' "

$% & '-)
&$. / .()

" "
1

3

3

(

(
" " *

3
'0

3

$

'0

(

"

3

(
$% & '(%$
'&0 1)( & '+2343& &

" "

(
(
(
+

+

+

"

" "
3

&"

(
"

" "

(

5
(

+

(

-

" "

0
( +
3
3
&"
( +
(
" "
3
&"
"
(
" "
-

( "
(
"

3

" "

( "
(

(

(
+"

)
(
(

(

(

3

/

(

+

(

" "
" "

5

:"
" "

(
+
.

!
)

"
$

" "

.

" "
(
''

.
,

" "

-

(
" "

" "

(
(
"

)

&

0"

3
" "

(
3

" "
(

(

"

" "

" "

(

(
(
5(

/

"

(

3

3

" "

3
(

3

(

" "

(

" "

"

5

" "
(
3
(

4 .

3

(

" "

)

&

(

(

,

0"
(

'''

(
#
" "

(
(

(

" "

" "

"
+

(
"
5

" "
.

"

(

" "
(

(
3

&"
3

' "

(

+

(

/

3

(
/
(
3

3

" "
" "

(
,
(

(
" "

"

" "

"
(

' "
%

&

&"

5

'&'( 6 &

&

$% & ' ()
7' %
32% %3&'+ - &

'-% (3+

&"

' "

(

&%('+

3

'&$$ &(%

&"

"

"
(
3
' "
3

&"

"

&"

"

(

"

"

"

(

&"

3

"

3
4 &

&"

"

' "

"

0

(

(

&

&"

+
"

(

"
"

3
&

&"

' "

' "

(
$

9

&

&"

3

"

' "

"

"

3
(

&"

"

3

1
(

3

(
(
(

*

(

(

2
(

(
"
&"

(

(
3
2

(

" "
3

' "
(
" "
(
3
&"
"

(

&"
"

"

(

"
"
"

(

&

"
(

2

3

3
(

&
4 0
(
"
0
(

+

&"

9

(

"

' "

&

" "
(
&
&"
&"
' "
" "
(
&

6

' "

9

(

&

(

&"

' "

(

(
(

3

&"

"

"

"

"

(

(

"

(

3

$% & '-)
'2 &$$% &
+

(
(
)

%4 .

)

(

+

(

+
(

"

(

(

3

(

3
#

#
&"

3

" "
"

(

#

)

3

(
(

3
3

5

$% & ' ()
+%& %6
!
)

3
&"

3
"

+
"

(

"
3
3

&"
&"

+
"
"

( "
3

(

3

"

(

"

"

(

&
" "
(
(

/
' "
2

+
!" "
(

(

"

"

$

#

$$%

$% & '-)
( * +
'+ %- &$ &
"
1
" "
" "

#
*

+

*
*

(

(

(

*

(

*
(

(
(

(

3
(

(

(

*

3

2
(
#
(

(

(

(
" &"
" .
(

' "
#
+
(
& (

&

1

' "

*
"

&"

(
' "

&"

,
(
(

3

(

(

(
0
(
&"

(

3
( "

(
( "

&' *
(
" "
4

"

+
"

&"
(

"

3

" "
4

"

"
&'
(

(" "

0

" "

0
(

#

2
(

(
3

" "
3

&"

(

#

.

5+

2
"
" "

(

" "

3

3

+

"

( "

(
(

(

(
(

(
0

"

"

( "

"

(

+
(

+
"

(

+

0

3

(
(

+

(

"

"
(

"

(
3

3

"

" "
&"
"
(
(

+

0

(
(
"

3

(

(

3

"

" "

+
3
(

(

(

3

3

(
(
(
"

&

(

(
(
!" "

(

#

$$%

' "

$% &
'2'+%.

&

"

3

&"

"

'(%$
& 8

(
(

)

(
(
" "
(
(

+
(
0
(

#

&

3
#

(

&"
" "

"

(

" "
&

3

&"

"

#

" "

+
" "

" "

(

3
&"

(

" "

(

!
&"

"

' "
*
(legal standing)

1
" "

"

3
*

+
"

#

" "

3

(

.

*
(

" "

(

"
0

(

" "
(

3
(
0

3

&"

(

"

(
"

(

" "
3
( "

(

(

(

(

3

(

(

3

(

(
"
&

3

(
(

&"
(
(
"

" "

"
( "

(

(

(

(

( ( "
4

(

&'

$% & ''26 (
'-% %
#
(

(

"

"

(

"

&

&"

' "
"

5(

(

(

"
(

(

(

(
(

3
4

" (

"
( "

(

(

3

"

(

"

(

+

(

(

(

(
"

(

3

2
/

"
"
' "

(

3

& (

&

&"

,
(

"
+

(

(
' "

&"

" &"
" .
(
' "
*
(
"
(

1
*
(

(

0

(
(

(

(
"

(

(
(
"

"

(

(

5(

+
"

(

(

3

(

<
(
5(
( (

(

(

(

(

3

(
(

(

3

"

(
+ (

+

3

((

( "
"

(

( "

(

" "
(

3

(

+

3

(

(

(

0

/

(

3
(

(

(

(

"
"

(

3

" "

"

&"

3

(
(

" "

(

' "
!
0

(

"

(

(

(
&

(
1
(
" "

(

+
(

*
((
(

(
*
( "

(

)

(

" *
(
(

(

*
*
*
"
(

(

"
(

(

"
"
"

(1)
&"

(

(

3

(
3

(2) &

(

(
"
(

(3)

3

&"

"

1
(

(

*

(

(

+ &"

*

' "

*
(

(

(

(

*

*

(

(
3

&"

#
(
(

(

( "

1
+

*
(

(

*

"

"
(

( "

(

(

*

+

(
#

+ (
*

3

" "

(

0

3
"

=
(
" "

1
*
*
((

+

(

*

*
" *
(

(
,

"
&"
(

3
#

(

(

3
3
(
(

"
(

)

(

&"

"

3

(
3

(

&

"
( "

&"

(

"

3
3

(

( "
3

((

(
(

4

(
(

$% & ' %2
'21).(% &

5

(

3

(

(

1
*
*
+

*
" "
(
(

3

#

" " *

( "
(
*

2

"
+

+ (

(

"

.

"(

(

3

(

"

3
+
(
3

(
(
&"

)
&"

"

(
"
&"

3

(

3

"

"

" "

(

#

" "

"
(

3

3

(

1

*
(

(
(

(

(

*
"
(

3

3

( +

(
2

3

&"

"

(

3

(

5
&"
&

(

3

"

" "

#

" "

3

"
(

(

"
"

3

"

(
(

&"
(

(

(

(

"

3

&"

"

(

"
(

3
*
(
(

(
(
+

(

1

(
*

7
(

3

3

( +
4

3

&"

"

(

"

3

(

)

(

(

3
(

)
3

&"

(

"

3

(
(

(

$% & ''& 2
'2'+%.
& '('26 (
!
3

&"
"
(
(
(
( "
(
"
(
"
" "
2
#
" "
(
3
&"
"
0
(
(
"
"
+
(
(
" "
0
(
(
(
(
"
3
&"
"
&"
"
(
(
&"
' "
#
+
(
(
3
& (
&
&"
' "

(

3

$% & '()7)4
' %26) &
+
%4 .
"
(
(
(

(
(

(

(

(

(

3
(

3

/

&"

+
+
"

(

&

(

(

(

3

(

(

$% & '-' 6 &
)() &
#
3

&"

"

(

"
+
(

0
&"

"

(

"
(

(
(

(

(
&
(

3

&"

"
"

(

3

(

,
3

&"

"

+ (
(

1
(
+

(

*
((

(

*

(
" "" *

1
" "

(

*

*
(

(
1.
2. (
3.
4.

3
(

(

(

*

*
1

(
3

(
(
(
(

*
*

*
(
(

5.
6.

*
3
+ (

(
3

&"
+

"
(
"

(

7.

3

&"

3

*
&"

3
"

&"

"

*

"

(

"

"

+
)
(
4 )
(

(

(
3

3

(
(

(

(
&"

%

3
+
(
' "

(

(

!
" "
&"
(
&

2

#
(

' "

" "

(
3

+
3

(
"

3

"

(

(
0

(

&"

(
(

(

3
&"

(

' "

(
&"

"
(
" "

(
"
4

(
(

(

&

"

" "

(

(

(
3

(
&"

" "
' "

(

(
(
#

" "

!
&

3

&"

"

3

" "
$

#

" "

( (

5

!
"
(
&"

(
' "
)

"

)
(
!" "
' "
)

' "
( (
(
#

((
(
$ $

' "
(

(

(
(

6

" "

(

"
((
((

" "

5

!
(
!" "

&"

#
+

$ $

"

' "
' "

)

!
;
&

(
&"

"

' "
!
3

5
!

( "
&"
' "
- (
' "

(
(

0
(

(

(

.

1<
1 %

$

((-

9

0
(

<
6 5(

$

((-

! ,

$

:
&"

' "
(

' "

"
(
!" "

+
&

' "
&"

' "
3

(

#

$$%
&'
(
(

( "

3

(

(
"

"

(

3

(
"

)

(
(

"
(
(

.

"

)
(
(

3
(
"

(
+
3

(
(

(
(
"
(
(

+ (
%

&

(
(

"
3
( "

(

3

0 6 43
+
(
"
0
"

( "
(

(
"

(
( "
3
(

(

"
"

(
quasi (

"
"

(

3

( "

"
(
&"
)

"
(

(
' "

(

(
!" "

#

$ $

' "

1
.
#
"
(
( "

(
(

(
$ $

&"

' "
(

+
(

!" "

(

( "
.

(

"

3

"

(

( "

3

( "

(

(
3

3

+ (

+ &

(
&"

) +

' "

!" "

#

$ $

(

1
*

3

*
" "
(
" "

+ (
(
( +
(
(
*
( "
3
(
(
(

(

+

3

(
(
(
(

(

(

(
(

(
+

(

(

:
>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5
;
>

(3

>

(3

;

;

+
8

(
(

(

+

5
>

(3

+
(

(

(

+

5

4
>

(3

>

(3

!
5
8

.
(

(

3

!

"

(
>"

5
'

.
(

" 1 &

.

"

!

"

-

& ("

#

"

.

!

"

'

0 -

- (

"

(

"
(

.

!

(

5
8

.
(

( "7

3

+

.

( ( "7

(

( "7

>"
"7

& ("

0 -0

0

&"

"
( "7

"7

" 0

.

( "7

-

" 1

"

)

0

"

0

( "7

(

-) 0

( "7

( "7

#

3

&"
3
"

#

' "

"7

" "

(

.
"

+

"

3

"7

5
8

.
(

(

3

+
(

>"
(

" 1

&
(

0

(

.
2 "

(

2 "

2 "
.

(

2 "

(

2 "

(

2&"
&"

0 -0
"

"

0

(

2 "

"

"

-) 0

(

#

(

(

2 "

3

&"
3

' "
#

" (

&

" "

2 "

(

2 "

(

2&"

(

2 "

.

" +
"

3

5
>

5

(3

4
>

(3
"

5
8

(

"(

"

(

"
&"

&"
' "

' "

"7

5
8

(

"(

"

"

&"
&"

#
5
>

(3

>

(3

5

(

' "

&

' "
(

"7
2&"

,
5
>

(3

>

(3

5

5
8

" "
" "

5
>

(3

5
;
>

(3

>

(3

;

;

+
>

(3

5
>

(3

5
>

(3

>

(3

>

(3

>

(3

>

(3

5

5

4

5
>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

5

5

!
5
>

(3

>

(3

>

(3

5

5

"
5
>

(3

>

(3

>

(3

>

(3

5

5

5

5

4
>

(3

#
5
8

?

"

@
(

" "

.

" "

+

.

"

" "

5
>

(3

>

(3

5

,
>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

5

5

4
>

(3

>

(3

5

8

(

"

5
>

(3

5
/

3

>

(3

>

(3

>

(3

5

5

5

4
>

(3

5
>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

!
5
>

(3

>

(3

>

(3

>

(3

5

5

5

"
>

(3

%

#
5
>

(3

>

(3

>

(3

5

5

,
5
>

(3

>

(3

5

5

"

" "

2
"

&"

"

3

(

5

"

#

" "

2
"

&"

"

>

(3

>

(3

>

(3

>

(3

>

(3

(

5

5

5

5

6

3

5
>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

5

!
5
>

(3

>

(3

>

(3

5

5

"
>

(3

#
5
>

(3

>

(3

>

(3

>

(3

5

5

5

5

4
>

(3

>

(3

5

5

/
$

>

(3

,
5
>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

5

5

5

5

5

>

(3
!

5

>

(3

>

(3

>

(3

5

5

"
5
>

(3

>

(3

>

(3

5

5

#
5
>

(3

>

(3

5

,
5
>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

5

5
>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

>

(3

5

5

5

5

5

5

5

5

5

4
>

(3

>

(3

>

(3

5

5

!
5
>

(3

>

(3

>

(3

5

5

5
>

(3
"

5
>

(3

>

(3

>

(3

5

5

#
5
>

(3

>

(3

>

(3

>

(3

5

5

5

,
5
>

(3

>

(3

>

(3

>

(3

5

5

5

5

4
>

(3

!
5
>

(3

>

(3

5

5

>

(3

>

(3

5

5

4
>

(3
!

>

(3

!
5
>

(3

>

(3

5

!
>

(3

!
>

(3

!
>

(3

4

<

!" " 1
(diisi oleh petugas)

# (1
9

:
!

2

1

1

,

2

(

2.

;

5
,
<
1
& +
"(
1

1

5

(
1

&
&"

(
2&" 1
" 1

(lingkari salah satu)

#
,

( 2#
1

!" " "
1
#
.
&# 2)' 2

3

1

&

1

1
&
1

'

" 1

; 1
!" '

A

1

1

(" 25

(lingkari salah satu)

:
!

(jika ada)

1

,

2

(

2.

5
,
<
1
& +
"(
1

;

(
1

&
&"

(
2&" 1
" 1

(lingkari salah satu)

*:
!

.

' "

1

0

& 3 1

" " 1

5

#

1

3
" "

2

1

1
(Nama dan Jabatan)

<

" "

' "

1

#
<

3
1

<

1

(Nama dan Jabatan)

5

&

1

#
&

3

2

1

1
(Nama dan Jabatan)

#

(

&

1

#
#

3
(

1

#

(

1

(Nama dan Jabatan)

5
sesuai)
5

" "

)
'0

"

(

" "
/

#
5

' "

1 (berikan tanda “√” terhadap pilihan yang

"

(

"
'0

+

&'
6
(

" "

&'

" "

(

(

(

5

'0

3
(
#

"

&'

" " 1

(berikan tanda “√” jika ada)
3
#
.

:
)

'

#

.

3

&

" "

&# 2)' 2
5

)
(
(

(" 2

)
" "
" "

(

2"

3

2"
.
2

.
2

)

&

#

<

(

5

'0

'0
(

" "

' "
0"

,

'+&; (

&

0
' "
(

'2343&
"
(
(

"

(

"

(

&"

' "

(
&"
"

(

" "

' "
(

3

(
(

B#

&"

( "
( "

5(

0
(

(
( "

.

( "

3

"
" "
(

(

"
(

3

" "

3

(

(
()7)4? 4 +% .'+7
" "
5(

( (
(

3

3
(

/

(
"

3

3

"
2

" "
(

(

(

6

" "

5(

3
(

"

/
3

(

3

3
(

" "

(

" "

" "

(
(
.

"

" "

(

(
(

"
(

" "

" "
"

3

$

D!" "

1 0

"
"

) &02

>"

" "

2

2&'
2 "7
2&
" 1 $$ 2'2&' ) &02 $

((-

9

$

(

5

:::::::::::::::::::

>&323+?@

A

EEEEEE
EEEEEEEEEE (
)

@>1) &?@( 4)&

EEEEEEEEEE

EEEEEEEEEE

' "

+

(

' "

EEEEEEEEE
.

-

" "

)

1
323+ BBBBBBBBBBBBBBBBBB
3

"

1

EEEEEEEEEEEEEEEEEEEEEEEEEEEE

3

'2343&
(
EEEEEEEEEEEEEEEEEEEEEEEEEEEE

3

'+2343&:
(
(

" "

' "

+
&"

.

-

' "
(

(
" "

#

)
(

(

" "

0

"
&%('+

:::::::::::::::::::::::::::::::::::::::::::::

((-

9

5

>&323+?@

A

EEEEEE
EEEEEEEEEE (

@>1) &?@( 4)&

EEEEEEEEEE

EEEEEEEEEE
(

EEEEEEEEEEEEE

&"
&"

EEEEEEEEE
' "

' "

EEEEEEEEEEEE

EEEEEEEEEEEEE

!" "

1

323+ BBBBBBBBBBBBBBBBBBBBB
(

" "

"

)

' "

3

1

EEEEEEEEEEEEEEEEEEEEEEEEEEEE

3

'2343&
(
EEEEEEEEEEEEEEEEEEEEEEEEEEEE

3

'+2343&:
.
#

4
$

&"

"
-

' "

)
(

' "

+

" "

" "

0

!" "

(

3

"

&%('+

:::::::::::::::::::::::::::::::::::::::::::::

((-

9