FORMULIR LAYANAN BANTUAN HUKUM GRATIS

                                            FORMULIR PERMOHONAN BANTUAN HUKUM

 

I.    IDENTITAS PEMOHON

 

Nama                            : ..................................................................................

Tempat/Tgl. Lahir           : ..................................................................................

Jenis Kelamin                 : ..................................................................................

Agama                          : ..................................................................................

Golongan Darah (*)        :

Alamat/Telepon/HP (*)   : ..................................................................................

Pekerjaan                      : ..................................................................................

Keterangan Miskin          : SKTM / JAMKESMAS / GAKIN / Terlampir

 

II.   URAIAN SINGKAT POKOK PERSOALAN

 

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

 

III.                                                                            Demikian permohonan ini saya buat dengan sesungguhnya untuk keperluan mendapat bantuan hukum

 

.............................., …………………2013

 

 

Pemohon

 

 

 

(­­­______________________)

 

Keterangan (*) : Bila ada

 

 

FORMULIR PERSETUJUAN / PENOLAKAN BANTUAN HUKUM

 

Yang bertanda tangan di bawah ini .....................................................................

Berkedudukan di ................................................................................................

Sesuai dengan permohonan bantuan hukum tertanggal ..........................................

Nama                          : ......................................................................

Tempat/Tgl. Lahir         : ......................................................................

Jenis Kelamin               : ......................................................................

Agama                        : ......................................................................

Golongan Darah (*)      :

Alamat/Telepon/HP (*) : ......................................................................

Pekerjaan                    : ......................................................................

Keterangan Miskin        : SKTM / JAMKESMAS / GAKIN / Terlampir

Dengan ini menerima / menolak (*) permohonan bantuan hukum dengan pertimbangan menurut syarat-syarat yang ditentukan.

Alasan penolakan (*) :

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

 

.............................., …………………20..

 

Nama Organisasi

Bantuan Hukum

 

 

 

Stempel

(Direktur)

 

Keterangan (*) : diisi bila ada penolakan

FORMULIR KONSULTASI BANTUAN HUKUM

 

I.         Data pemohon / klien

1.     Nama                                       :..................................................................

2.     Tempat / tinggal lahir                :..................................................................

3.     Jenis kelamin                            :..................................................................

4.     Kawin/belum kawin/duda/janda   :..................................................................

5.     Tempat tinggal (alamat)             :..................................................................

Kelurahan/desa                          :..................................................................

Kecamatan                                :..................................................................

Kabupaten/kota                         :..................................................................

6.     Pendidikan                                :..................................................................

Pekerjaan                                 :                                                                        

 

II.       Pelaksanaan konsultasi hukum (tanggal/bulan/tahun).

........................................................................................................................

........................................................................................................................

III.     Uraian Singkat Pokok Masalah dan Latar Belakangnya.

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

IV.      Nasihat yang diberikan Konsultan termasuk Aspek Yuridisnya.

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

V.        Hasil akhir konsultasi.

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

 

VI.      Kesan konsultasi atas tingkat pengetahuan / kesadaran hukum pemohon.

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

VII.    Pemohon / Klien

Nama                      :                                                                                         

Tanda tangan           :                                                                                         

 

VIII.  Konsultasi Hukum

Nama                      :   ......................................................................................

Tanda tangan           :   ......................................................................................

 

 

 

.............................., …………………20..

 

Mengetahui,

 

PUSAT ADVOKASI & BANTUAN HUKUM ORANG INDONESIA

 

 

 

 

 

Khair khalis syurkati. SH. MH.

Direktur

 

 

 

FORMULIR SISTEMATIKA PROPOSAL PENELITIAN

 

I.         Latar Belakang

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

II.       Permasalahan / Ruang Lingkup

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

III.     Tujuan dan Kegunaan Penelitian

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

IV.      Metode Penelitian

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

V.        Tinjauan Teoritis / Konsepsional

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

VI.      Tempat Penelitian

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

 

 

VII.    Jangka Waktu Penelitian

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

VIII.  Susunan Organisasi Tim Penelitian

........................................................................................................................

........................................................................................................................

........................................................................................................................

........................................................................................................................

 

 

.............................., …………………20..

 

Mengetahui,

 

PATUH OI

 

 

 

 

Khair khalis syurkati, SH., MH.

Direktur

 

 

 

FORMULIR SISTEMATIKA LAPORAN AKHIR PENELITIAN

 

 

BAB I  Pendahuluan

A.   Latar Belakang

B.    Permasalahan/Ruang Lingkup

C.   Tujuan dan Kegunaan Penelitian

D.   Metode Penelitian

E.    Tinjauan Teoritis/Konsepsional

F.    Tempat Penelitian

G.   Jangka Waktu Penelitian

H.   Susunan Organisasi Tim Penelitian

BAB II Tinjauan/Data Kepustakaan

A.   …..

B.    …..

BAB III         Tinjauan/Data Lapangan

A.   …..

B.    …..

BAB IV         Analisis

A.   …..

B.    …..

BAB V Penutup

A.   Kesimpulan

B.    saran

 

 

 

 

 

 

 

 

FORMULIR PELAKSANAAN KEGIATAN PEMBERDAYAAN HUKUM

 

Pada hari ini …………….. tanggal …………….. bulan …………….. tahun …………….. , (nama pemberi bantuan hukum) yang berkedudukan di ……………..……………..……………..………

Telah melaksanakan kegiatan pemberdayaan hukum berupa :

a.    Jenis kegiata.........................................................................................................      

b.    Jumlah peserta......................................................................................................      

c.    Jangka waktu pelaksanaan.....................................................................................      

d.    Hasil/output  kegiatan............................................................................................      

e.    Jenis keterampilan hukum yang telah didapatkan peserta ­­………………………………………

...........................................................................................................................

...........................................................................................................................

 

.............................., …………………20 …….   Nomor         : Perihal         : Pendampingan di luar pengadilan   Kepada Yth   :   Direktur PUSAT ADVOKASI & BANTUAN HUKUM  ORANG INDONESIA (PATUH-OI)   Di – Tempat   Saya yang bertanda tangan di bawah ini : 1.    Nama                                        :   ....................................................................... 2.    Tempat / tinggal lahir                 :   ....................................................................... 3.    Jenis kelamin                             :   ....................................................................... 4.    Kawin/belum kawin/duda/janda    :   ....................................................................... 5.    Tempat tinggal (alamat)              :   ....................................................................... Kelurahan/desa                          :......................................................................... Kecamatan                                :......................................................................... Kabupaten/kota                         :......................................................................... 6.    Pendidikan                                 :   ....................................................................... Pekerjaan                                  :   .......................................................................   Bersama ini saya mengajukan permohonan bantuan untuk penyusunan/pembuatan drafting hukum dalam rangka kegiatan : ................................................................................................................................ ................................................................................................................................ ................................................................................................................................   Demikian permohonan ini kami ajukan untuk disetujui   Pemohon ………………………………..

 

 

FORMULIR MEDIASI

 

Pada hari ini ……………………., tanggal ………, bulan ………………………., tahun ………………

telah dilaksanakan mediasi …………………………………………………………………………… antara ………………………………….. yang beralamatkan di ………………………………………….. selanjutnya disebut dengan PIHAK I dengan  ………………………………………………. Yang beralamat di ………………………………….. selanjutnya disebut PIHAK II dalam perkara ……………………………………………………………………………………………………………………………

 

Adapun butir-butir kesepakatan mediasi yang dihasilkan adalah sebagai berikut :

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

 

PIHAK PERTAMA         Ttd (………………………..)

PIHAK KEDUA         Ttd (………………………..)

 

 

MEDIATOR

 

 

 

 

(……………………………………….)

 

 

 

 

 

FORMULIR KONSILIASI

 

Pada hari ini ……………………., tanggal ………, bulan ………………………., tahun ………………

telah dilaksanakan konsiliasi …………………………………………………………………………… antara ………………………………….. yang beralamatkan di ………………………………………….. selanjutnya disebut dengan PIHAK I dengan  ………………………………………………. Yang beralamat di ………………………………….. selanjutnya disebut PIHAK II dalam perkara ………………………………………………………………………………………………………………………………

 

Adapun butir-butir kesepakatan konsiliasi yang dihasilkan adalah sebagai berikut :

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

 

PIHAK PERTAMA         Ttd (………………………..)

PIHAK KEDUA         Ttd (………………………..)

 

 

KONSILATOR

 

 

 

 

(……………………………………….)

 

 

 

FORMULIR INVESTIGASI

 

Pada hari ini ……………………., tanggal ………, bulan ………………………., tahun ……………

telah dilaksanakan proses investigasi atas perkara …………………………………………………………… antara ………………………………….. yang beralamatkan di ………………………………………….. selanjutnya disebut dengan PIHAK I dengan  ………………………………………………. Yang beralamat di ………………………………….. selanjutnya disebut PIHAK II dalam perkara ………………………………………………………………………………………………………………………

 

Adapun hasil investigasi adalah sebagai berikut :

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

 

 

 

 

INVESTIGATOR

 

 

 

 

(……………………………………….)

 

 

 

 

FORMULIR PROPOSAL

PENGAJUAN PROGRAM BANTUAN HUKUM

 

 

Nama organisasi bantuan hukum   : ............................................................................

Alamat                                       : ............................................................................

Nama Program                            : ............................................................................

Tujuan Program                           : ............................................................................

Deskripsi Program                       : ............................................................................

 

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

................................................................................................................................

 

Target pelaksanaan                      : ............................................................................

Output yang diharapkan               : ............................................................................

Jadwal pelaksanaan                     : ............................................................................

Rincian biaya program                  : ............................................................................

 

 

Nama Organisasi Bantuan Hukum

 

 

 

 

Stempel basah

…………………………………….

Direktur