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
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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 (*) :
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…………………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).
........................................................................................................................
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III. Uraian
Singkat Pokok Masalah dan Latar Belakangnya.
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IV. Nasihat
yang diberikan Konsultan termasuk Aspek Yuridisnya.
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V.
Hasil akhir konsultasi.
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VI. Kesan
konsultasi atas tingkat pengetahuan / kesadaran hukum pemohon.
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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
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II. Permasalahan
/ Ruang Lingkup
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III. Tujuan
dan Kegunaan Penelitian
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IV. Metode
Penelitian
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V.
Tinjauan Teoritis / Konsepsional
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VI. Tempat
Penelitian
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VII. Jangka
Waktu Penelitian
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VIII. Susunan
Organisasi Tim Penelitian
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..............................,
…………………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 :
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
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|
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 :
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................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
INVESTIGATOR
(……………………………………….)
FORMULIR PROPOSAL
PENGAJUAN PROGRAM BANTUAN HUKUM
Nama organisasi bantuan
hukum : ............................................................................
Alamat : ............................................................................
Nama Program : ............................................................................
Tujuan Program : ............................................................................
Deskripsi Program : ............................................................................
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Target pelaksanaan : ............................................................................
Output yang diharapkan : ............................................................................
Jadwal pelaksanaan : ............................................................................
Rincian biaya program : ............................................................................
Nama
Organisasi Bantuan Hukum
Stempel basah
…………………………………….
Direktur
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