ࡱ> _ bjbj }bb bb,\֌fNNNNNwwwUWWWWWW$<V{ww@www{bbNNZbЁЁЁwb8NNUЁwUЁЁrTN 8pA0֌DBDDwwЁwwwww{{Ā www֌wwwwDwwwwwwwww (:  PERNYATAAN KEBERATAN ATAS PERMOHONAN INFORMASI INFORMASI PENGAJUAN KEBERATAN Nomor Registrasi Keberatan : _______________________________________________ (diisi petugas)* Nomor Pendaftaran Permohonan Informasi : _________________________________________________________ Tujuan Penggunaan Informasi : _________________________________________________________ Identitas Pemohon Nama : _________________________________________________________ Alamat : _________________________________________________________ _________________________________________________________ Pekerjaan : _________________________________________________________ Nomor Telepon : _________________________________________________________ Identitas Kuasa Pemohon ** Nama : __________________________________________________________ Alamat : __________________________________________________________ __________________________________________________________ Nomor Telepon : __________________________________________________________ ALASAN PENGAJUAN KEBERATAN ***  - Permohonan Informasi di tolak. - Informasi berkala tidak disediakan. - Permintaan informasi tidak ditanggapi - Permintaan informasi ditanggapi tidak sebagaimana yang diminta - Permintaan informasi tidak dipenuhi - Biaya yang dikenakan tidak wajar - Informasi disampaikan melebihi jangka waktu yang ditentukan KASUS POSISI (tambahkan kertas bila perlu) ______________________________________________________________________________________________ ______________________________________________________________________________________________ HARI/TANGGAL TANGGAPAN ATAS KEBERATAN AKAN DIBERIKAN : [tanggal],[bulan],[tahun] (diisi oleh petugas)*** Demikian keberatan ini saya sampaikan, atas perhatian dan tanggapannya, saya ucapkan terima kasih. . 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