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Form 2

 BUKU MONOGRAFI KELURAHAN

KEADAAN PADA BULAN ……………. TAHUN ……...

 

1. Nama Kelurahan : ...............................................................

2. Tahun Pembentukan

: ...............................................................

3. Dasar Hukum Pembentukan : ...............................................................

4. Nomor Kode Wilayah : ...............................................................

5. Nomor Kode Pos : ...............................................................

. Ke!amatan : ......................................................

.........

". Kabu#aten$Kota : ...............................................................

%. Pro&insi : ...............................................................

A. DATA UMUM

1.  Ti#olo'i Kelurahan   :  a. Persa(ahan

b. Perladan'an

!. Perkebunan

d. Peternakan

e. Nelayan

). Pertamban'an $ 'alian

'. Kera*inan dan industri ke!il

h. +ndustri sedan' dan besar

i.  ,asa dan #erda'an'an

2. -uas Wilayah

: ........................................................ km2

3. atas Wilayah:

1. /ebelah 0tara :....................................................................

2. /ebelah /elatan: ....................................................................

3. /ebelah arat: ....................................................................

4. /ebelah Timur : ...............................................................

4. rbitrasi ,arak dari Pusat Pemerintahan:

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 ,arak dari Pusat Pemerintahan Ke!amatan : ..................................km ,arak dari Pusat Pemerintahan Kota : ..................................km ,arak dari kota$+bukota Kabu#aten : ..................................km ,arak dari +bukota Pro&insi : .................................. km

5.  ,umlah Penduduk : ..........................

 ,i(a ...................... KK 

a. -akilaki

: ........................................................ ,i(ab. Perem#uan : ........................................................ ,i(a

!. 0sia 6 7 15 : 88888888888888...888..8.

 ,i(a

0sia 15 7 5 : 88888888888888888...8...

 ,i(a

0sia 5 keatas : 88888888888888.888....8.

 ,i(a

. Peker*aan$9ata Pen!ahariana. Karya(an :1 Pe'a(ai Ne'eri /i#il : .........................................................

oran'.2 ; + : .........................................................

oran'.3 /(asta : .........................................................

oran'.b. Wiras(asta$#eda'an' : .........................................................

oran'.!. T a n i : .........................................................

oran'.d. Pertukan'an : .........................................................

oran'.e. uruh Tani : .........................................................

oran'.). Pensiunan : .........................................................

oran'.'. Nelayan : .........................................................

oran'.h. Pemulun' : .........................................................

oran'.

i. , a s a : .........................................................oran'.

".  Tin'kat #endidikan masyarakat:

a. -ulusan Pendidikan 0mum1 Taman Kanakkanak : .........................................................

oran'.

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2 /ekolah Dasar : .........................................................oran'.

3 /9P : .........................................................oran'.

4 /9$/90 : .........................................................oran'.

5 kademi$D1D3 : .........................................................oran'.

/ar*ana : .........................................................oran'.

" Pas!asar*ana : .........................................................oran'.

b. -ulusan Pendidikan Khusus1 Pondok Pesantren

: ......................................................... oran'.2 Pendidikan Kea'amaan

: ......................................................... oran'.3 /ekolah -uar iasa

: ......................................................... oran'.4 Kursus Keteram#ilan : .........................................................

oran'.

%. ,umlah Penduduk 9iskin : ........................ *i(a ....................... KK   menurut standar P/

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d. Prasarana +badah1. 9es*id : ...........................................................buah2. 9ushola : ..............888888888888........buah3. =ere*a : ...........................................................buah4. Pura : 8888..88888888....................buah5. >ihara : ...........................................................buah. Klenten' : 8888..88888888....................buah

e. Prasarana 0mum1. lahra'a : ...........................................................buah2. Kesenian $ udaya

: ........................................................... buah3. alai #ertemuan

: ........................................................... buah

4. -ainnya ................. : ........................................................... buah

B. DATA PERSONIL

1. Ke#ala Kelurahan -urah

a.

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

b.

Pan'kat $ =ol: .........................................................

!

.

N + P: .........................................................

d.

Pendidikan: .........................................................

e.

 T9T 9asa ,abatan: .........................................................

). ;i(ayat ,abatan : 1.......................................................: 2.......................................................: 3.......................................................

'.

 ,enis kelamin: .........................................................

2. /ekretaris -urah

a.

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

b.

Pan'kat $ =ol: .........................................................

! N + P : .........................................................

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.d.

Pendidikan: .........................................................

e.

 T9T 9asa ,abatan: .........................................................

). ;i(ayat ,abatan : 1.......................................................: 2.......................................................: 3.......................................................

'.

 ,enis kelamin: .........................................................

3. ,umlah #arat Kantor Kelurahan

a. =olon'an +: ........................................................... ran'

b. =olon'an ++: ........................................................... ran'

!. =olon'an +++ : ........................................................... ran'

d. =olon'an +> : ........................................................... ran'

C. DATA KEWENANGAN

1. ,umlah urusan yan' dilim#ahkan Kabu#aten$Kota : 8888888..88.

2. 0rusan yan' dilim#ahkan oleh Kabu#aten$Kota : 8888888..88.

a. 0rusan Wa*ib idan' : 1. ..........................................................................

2. .........................................................................3. ......................................................................... dst.

0rusan : 1. ..........................................................................2. .........................................................................

3. ......................................................................... dst. ,umlah : ..............................................................................urusan

b. 0rusan Pilihan

idan' : 1. ........................................................................2. ........................................................................3. ........................................................................ dst.

0rusan : 1. ........................................................................2. ........................................................................

3. ........................................................................ dst. ,umlah : .............................................................................urusan

3. ,umlah Pro'ram yan' diterima Kelurahan :

a. Pemerintah Pusat :

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,umlah ke'iatan #er bulan : ...............................ke'iatan

  ,umlah dana yan' dikelola : ;# ..............................2. PKK 

,umlah #en'urus : ...................................oran' ,umlah an''ota : ...................................oran' ,umlah ke'iatan #er bulan : ...............................ke'iatan ,umlah buku administrasi yan' dikelola :

.................................... buah ,umlah dana yan' dikelola :;# ...............................

3. Karan' Taruna

,umlah Karan' Taruna : .................................... buah ,enis Karan' Taruna: ....................................

,umlah Pen'urus ratarata : ....................................4. ;T$;W

a. ,umlah ;W

: .................................... buahb. ,umlah ;T : .................................... buah!. ;atarata #en'hasilan Ketua ;W dalam sebulan:;# ..............................d. ;atarata #en'hasilan Ketua ;T dalam sebulan :;# ...............................

5. -emba'a Kemasyarakatan -ainnya

a. ,umlah : ....................................................................buahb. Nama : 1........................ ,ml Pen'urus : ..............

ran'   2........................ ,ml Pen'urus : ..............ran'

F. KETENTRAMAN DAN KETERTIBAN

  1. ,umlah n''ota -inmas

: .................................... oran'

  2. ,umlah Pos Kamlin' : .................................... #os

  3. ,umlah #erasi Penertiban : .................................... kali

  4. ,umlah Ke*adian Kriminal

a. Pen!urian : .................................... kalib. Perkosaan : .................................... kali

!. Kenakalan ;ema*a : .................................... kali

d. Pembunuhan : .................................... kali

e. Peram#okan : .................................... kali

). Peni#uan : .................................... kali

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  5. ,umlah Ke*adian en!ana

: .................................... kali

. ,umlah Pos en!ana lam : .................................... #os

". ,umlah Pembalakan -iar

: .................................... kali

%. ,umlah Pos Hutan -indun' : .................................... #os