SURAT PERINTAH PENGGELEDAHAN

KEPOLISIAN REPUBLIK INDONESIA

        DAERAH JAWA TIMUR

           WILAYAH MALANG

Logo Kepolisian RI

_________________________

            PRO JUSTITIA

                        SURAT PERINTAH PENGGELEDAHAN

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

PERTIMBANGAN       : Untuk kepentingan penyidikan tindak pidana, perlu dilakukan                                  tindakan penggeledahan rumah.

DASAR                       : 1. Pasal 1 butir 17, pasal 5 ayat (1) huruf b angka 1, pasal 7                                       ayat (1) huruf d, pasal 11, pasal 32, pasal 125, pasal 126,                                 pasal 127 KUHP.

                                   2. Laporan Polisi No, Pol, : .....................tanggal.....................

                                   3. Permintaan dari.....................................................................

                                   4. Surat izin penggeledahan dari Ketua Pengadolan Negeri                                                     .................No, ................ tanggal .........................................

                                             

                                              DIPERINTAHKAN

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

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

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

                                    2.       Nama              : ...............................................

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

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

UNTUK                      : 1.       Melakukan penggeledahan rumah                                                                            dari..........................\terletak di,                                                                                ............................., guna melakukan................

                                              a. Pemeriksaan, dan. Atau

                                              b. Penyitaan, dan atau

                                              c. Penangkapan

                                              Sehubungan dengan terjadinya tindak                                                                       pidana.........................sebagaimana dimaksud dalam                                               pasal..................................................................................

                                   2. Dalam waktu dua hari setelah melaksanakan Surat Perintah                                    ini harus membuat Berita Acara Penggeledahan.

                                                                                  DIKELUARKAN DI ; ..............

                                                                                  PADA TANGGAL  ...............

                                                                                  KEPALA ................

                                                                                                    Selaku

                                                                                  Penyidik/Penyelidik Pembantu

                                                                                 

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

                                                                                  ....................Nrp.......................

                                 

Tanda Tangan                                                                       KEPALA.................................

Yang Menerima  Perintah                                                    Selaku

                                                                                  Penyidik/Pnyidik Pembantu

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

                                                                                  ....................Nrp....................