PEMERINTAH KABUPATEN NGANJUK

KECAMATAN JATIKALEN

PEJABAT PENGELOLA INFORMASI DAN DOKUMENTASI

Kabupaten Nganjuk

Jalan Raya Jatikalen No. 23 Kode Pos. 64392

 Email : jatikalen@nganjukkab.go.id

FORM KEBERATAN

(RANGKAP DUA)

PERNYATAAN KEBERATAN ATAS PERMOHONAN INFORMASI

 

A.INFORMASI PENGAJU KEBERATAN

Nomor Registrasi Keberatan        :                                    ...........................................................................................

Nomor Permohonan Informasi     :                                    ...........................................................................................

Alasan Permohonan Informasi     : ...................................................................................................................................

 

 

Identitas Pemohon

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

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

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No Telpon / Email                        : ....................................................................................................................................

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

 

Identitas Kuasa Pemohon

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

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

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No Telpon / Email                        : ....................................................................................................................................

 

B.ALASAN KEBERATAN

1. Permohonan Informasi ditolak
2. Informasi berkala tidak disediakan
3. Permintaan informasi tidak ditanggapi
4. Permintaan informasi ditanggapi tidak sebagaimana yang diminta
5. Permintaan informasi tidak dipenuhi
6. Biaya yang dikenakan tidak wajar
7. Informasi disampaikan melebihi jangka waktu yang ditentukan

 

C.KASUS POSISI (tambahkan kertas bila perlu)

 

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D.HARI / TANGGAL TANGGAPAN ATAS KEBERATAN AKAN DIBERIKAN :

 

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Demikian keberatan ini saya sampaikan, atas perhatian dan tanggapannya, saya ucapkan terima kasih.

 

Nganjuk, .......................................

 

Petugas Pelayanan Informasi (Penerima Keberatan)

Pengaju Keberatan