BERITA ACARA MUSDES KHUSUS/MUSDES INSIDENTIL PEMBENTUKAN KOPERASI DESA/KELURAHAN MERAH PUTIH

 BERITA ACARA

MUSDES KHUSUS/MUSDES INSIDENTIL

PEMBENTUKAN KOPERASI DESA/KELURAHAN MERAH PUTIH

DESA ........ KECAMATAN CIPTA DESA KABUPATEN SITUBONDO

Berkaitan dengan pelaksanaan kegiatan Musyawarah Desa Khusus/Musyawarah Desa Insidentil di Desa ……… Kecamatan Cipta Desa Kabupaten Situbondo Provinsi Jawa Timur dalam rangka pembentukan Koperasi Desa Merah Putih, maka pada hari ini:

Hari dan Tanggal : ………… dan ……………… 20...

Jam : 00.00 WIB s/d. selesai

Tempat : ………………………………………

telah diadakan kegiatan Musyawarah Desa Khusus atau Musyawarah Desa Insidentil tentang pembentukan Koperasi Desa/Kelurahan Merah Putih, yang dihadiri oleh Pemerintah Desa, BPD, dan Wakil Kelompok Masyarakat Desa serta unsur lain yang terkait Desa, sebagaimana tercantum dalam daftar hadir terlampir.

Materi yang dibahas serta yang bertindak selaku unsur pimpinan rapat dan narasumber dalam membahas kegiatan musyawarah Desa Khusus/musyawarah Desa adalah:

1. Materi

1. Penjelasan maksud dan tujuan pembentukan Koperasi Desa/Kelurahan Merah Putih;

2. Pembahasan nama koperasi;

3. Pembahasan kedudukan/alamat koperasi;

4. Pembahasan bentuk koperasi;

5. Pembahasan wilayah keanggotaan;

6. Pembahasan jangka waktu berdiri;

7. Pembahasan usaha koperasi;

8. Pembahasan permodalan (simpanan pokok, simpanan wajib, hibah) dan modal pendirian koperasi;

9. Pembahasan susunan pengurus dan pengawas;

10. Pembahasan periode jabatan susunan pengurus dan pengawas;

11. Pembahasan anggaran dasar koperasi; dan

12. Masukan dan saran.

2. Unsur Pimpinan Rapat dan Narasumber

Pemimpin Musyawarah : …..……………………........................ dari .........

Notulen : …..……………………........................ dari .........

Narasumber : 1. …..…………………….................... dari .........

2. …..…………………….................... dari .........

3. …..…………………….................... dari .........

4. …..…………………….................... dari .........

5. …..…………………….................... dari .........

Setelah dilakukan pembahasan dan diskusi terhadap materi, selanjutnya seluruh peserta musyawarah Desa Khusus atau Musyawarah Desa Insidentil menyepakati beberapa hal yang berketetapan menjadi kesepakatan akhir dari Musyawarah Desa Khusus/musyawarah Desa Insidentil tentang pembentukan Koperasi Desa/Kelurahan Merah Putih yaitu:

1. Menyetujui Nama :

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

2. Menyetujui kedudukan/alamat :

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

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

3. Menyetujui bentuk :

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

4. Menyetujui wilayah keanggotaan :

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

5. Menyetujui jangka waktu berdiri :

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

6. Menyetujui usaha koperasi :

1. ..................................................................................................................

2. ..................................................................................................................

3. ..................................................................................................................

4. ..................................................................................................................

5. ..................................................................................................................

6. dan seterusnya..........................................................................................

7. Menyetujui simpanan anggota :

• Simpanan pokok Rp .........................................../orang

• Simpanan wajib Rp ............................................./bulan/orang

8. Modal pendirian koperasi Rp..........................................,-

Terdiri dari :

• Simpanan Pokok (akumulasi dari semua jumlah pendiri)

Rp ...................................................................................,-

• Simpanan Wajib (akumulasi dari semua jumlah pendiri)

Rp ...................................................................................,-

• Hibah (jika Koperasi menerima hibah yang dapat dibuktikan dengan surat pernyataan atau . akta notaris)

Rp ...................................................................................,-

9. Menyetujui susunan Pengurus (terlampir)

10. Menyetujui susunan Pengawas (terlampir)

11. Menyetujui masa kerja pengurus dan pengawas ...................tahun

12. Menyetujui Anggaran Dasar Koperasi.

13. Menunjuk dan memberi kuasa kepada Pengurus Koperasi sebagai Kuasa Pendiri, yaitu :

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

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

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

No. KTP : ...........................................................................................

Jabatan : ...........................................................................................

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

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

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

No. KTP : ...........................................................................................

Jabatan : ...........................................................................................

3. Nama : ...........................................................................................

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

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

No. KTP : ...........................................................................................

Jabatan : ...........................................................................................

Untuk menghadap dan menandatangani minuta akta pendirian koperasi di hadapan Notaris Pembuat Akta Koperasi (NPAK).

Demikian berita acara ini dibuat dan disahkan dengan penuh tanggungjawab agar dapat dipergunakan sebagaimana mestinya.

Kepala Desa .................. Nama, tanda tangan & cap ..........................................	...nama desa..., ................ 20.... Ketua BPD Nama, tanda tangan & cap ..........................................
Mengetahui dan Menyetujui
Wakil Masyarakat …………………………………………… …………………………………………… …………………………………………… …………………………………………… ……………………………………………	Tanda Tangan …………………………… ……………………… …………………………… ……………………… ……………………………

NOTULENSI

MUSDES KHUSUS/MUSDES INSIDENTIL

PEMBENTUKAN KOPERASI DESA/KELURAHAN MERAH PUTIH

DESA ........ KECAMATAN CIPTA DESA KABUPATEN SITUBONDO

Agenda Kegiatan : Musyawarah Desa Khusus / Musdes Insidentil tentang Pembentukan Koperasi Desa/Kelurahan Merah Putih Hari dan Tanggal : ……………… dan ………………… 20... Jam : 00.00 WIB s/d. selesai. Notulen: ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ............................................................................................................................ ....nama desa, ..... - ..... – 20... Notulis, ...................................

DAFTAR HADIR

MUSDES KHUSUS/MUSDES INSIDENTIL

PEMBENTUKAN KOPERASI DESA/KELURAHAN MERAH PUTIH

DESA ........ KECAMATAN CIPTA DESA KABUPATEN SITUBONDO

NO	NAMA	L/P	ALAMAT	JABATAN	TANDA TANGAN
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Kepala Desa .................. Nama, tanda tangan & cap ..........................................

...nama desa..., ................ 20.... Ketua BPD Nama, tanda tangan & cap ..........................................

SUSUNAN PENGURUS

KOPERASI ……………………….
PERIODE 20... s/d. 20..

• KETUA

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

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

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

No. KTP : ...........................................................................................

• WAKIL KETUA Bidang Usaha

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

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

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

No. KTP : ...........................................................................................

• WAKIL KETUA Bidang Anggota

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

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

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

No. KTP : ...........................................................................................

• SEKRETARIS

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

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

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

No. KTP : ...........................................................................................

• BENDAHARA

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

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

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

No. KTP : ...........................................................................................

*Bisa ditambahkan sesuai dengan kebutuhan

SUSUNAN PENGAWAS

KOPERASI ……………………….
PERIODE 20... s/d. 20..

• KETUA

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

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

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

No. KTP : ...........................................................................................

• ANGGOTA

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

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

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

No. KTP : ...........................................................................................

• ANGGOTA

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

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

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

No. KTP : ...........................................................................................

*bisa ditambahkan sesuai dengan kebutuhan

REKAPITULASI MODAL
( SIMPANAN POKOK DAN SIMPANAN WAJIB )

KOPERASI………………………

NO	NAMA	SIMPANAN POKOK (Rp)	SIMPANAN WAJIB (Rp)	JUMLAH (Rp)
(1)	(2)	(3)	(4)	(5)
1.
2.
3.
4.
5.
6.
7.
8.
			TOTAL

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