Surat Izin penggeledahan

Logo Kepolisian RI

                            

KEPOLISIAN REPUBLIK INDONESIA                                         Malang, ......................., 2013

        DAERAH JAWA TIMUR

           WILAYAH MALANG

____________________________

            PRO JUSTITIA

No.Pol              : ..................................

Klasifikasi        : Biasa

Lampiran         :.......bendel

Perihal             : Surat Izin penggeledahan

                                                                                                                  Kepada

                                                                                       Yth. Ketua Pengadilan Negeri Malang 

                                                                                              Di

                                                                                              MALANG  

                                                                                                                                                                          

          1.         Berdasarkan :

                      a. Laporan Polisi No,Pol, : ....................................................................

                          tanggal ...............................................................................................

                      b. ............................................................................................................

                      c. ............................................................................................................

                      Tersangka :

                      Nma                            : .........................................

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

                      Tempat/tgl lahir         : ..........................................

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

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

                      Kewarganegaraan      : ..........................................

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

                      Diduga telah melakukan tindak pidana....................................................

                      Sebagaimana

                      Dimaksud dalam pasal.............................................................................

          2. Untuk kepentingan penyidikan diperlukan tindakan hukum berupa :

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

3. Guna keperluan tersebut diharapkan Ketua dapat menerbitkan surat izin                 yang dimaksud.

          4. Demikian untuk menjadikan maklum dan mengharap keputusan.

                                                                                  Kepala ...........................................

                                                                                              Selaku

                                                                                  Penyidik/Penyidik Pembantu

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

                                                                                  Pangkat..............?Nrp...........