BERITA ACARA

MUSYAWARAH DESA
PENETAPAN DATA SDGs DESA 2021
DESA ......

Dalam rangka pelaksanaan Pendataan Desa berbasis Sustainable

Development Goals (SDGs) Desa 2021, di Desa…………..Kecamatan………….
Kabupaten Manggarai Barat, Provinsi Nusa Tenggara Timur maka pada:

Hari dan Tanggal : ...........................................................................

Jam : .................................................................
Tempat : ...........................................................................

Telah dilaksanakan Musyawarah Desa SDGs 2021 yang dihadiri oleh

Pemerintah Desa, BPD, dan Wakil Kelompok Masyarakat Desa serta unsur lain
yang terkait sebagaimana daftar hadir terlampir.

Materi yang dibahas dalam Musyawarah ini serta yang bertindak selaku
unsur pemimpin musyawarah dan narasumber adalah:
A. Agenda/Materi
1. Penyampaian Pencapaian SDGs Desa;
2. Evaluasi dan Pembahasan Pencapaian SDGs Desa Tahun 2021; dan
3. Penetapan SDGs Desa.
B. Unsur Pemimpin Musyawarah dan Narasumber

1. Pemimpin Musdes : ………………………............ dari Ketua BPD

2. Notulen : ………………………............. dari Anggota BPD

Narasumber : 1. ………………………......... dari Kepala Desa

2. ………………………......... dari Kecamatan

3. ………………………......... dari Pendamping Desa

Setelah dilakukan pembahasan dan diskusi terhadap materi, selanjutnya

seluruh peserta musyawarah desa menyepakati beberapa hal yang
berketetapan menjadi kesepakatan akhir dari musyawarah desa Penetapan
Data SDGs Desa 202, yaitu:
1. Kegiatan sudah berjalan dari .....(tanggal mulai pendataan)...... - .....
(tanggal selesai pendataan)...... dengan melakukan pendataan individu,
keluarga, RT, dan desa dengan data pencapaian SDGs sebagaimana
tampak pada tabel berikut ini.

Pendataan Jumlah Pendataan

1. Desa ............
2. RT/RW ............
3. Data Kelaurga ............
 4. Data Individu ............
2. Penetapan data SDGs Desa ................ 2021 dengan mendata kategori
data individu, pekerjaan, penghasilan, kesehatan, difabilitas, dan
pendidikan telah mencapai 100% pendataan dengan lampiran data yang
tidak terpisahkan dengan Berita Acara ini.

3. Menentapkan data SDGs Desa .......... 2021 sesuai dengan lampiran data
yang tidak terpisahkan dalam Berita Acara ini

Keputusan diambil secara musyawarah mufakat.

Demikian Berita Acara ini dibuat dan disahkan dengan penuh tanggung
jawab agar dapat dipergunakan sebagaimana mestinya.

...Nama Desa..., .......................

Kepala Desa .................. Ketua BPD

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

Mengetahui dan Menyetujui

Wakil Masyarakat Tanda Tangan

1. …………………………………………… 1. ……………………………

2. …………………………………………… 2. ………………………

3. …………………………………………… 3. ……………………………

4. …………………………………………… 4. ………………………

5. …………………………………………… 5. ……………………………
 PEMERINTAH KABUPATEN MANGGARAI BARAT
KECAMATAN……
DESA..... ……………
Jln. ................................... Kode Pos: .........

NOTULENSI
MUSYAWARAH DESA
PENETAPAN DATA SDGs DESA 2021

Hari/Tanggal : …….........……………
Waktu : …….........……………
Tempat : …….........……………
Agenda : …….........……………
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...Nama Desa..., ....................... 2021

Pimpinan Rapat Notulensi

............................. .............................
 DAFTAR HADIR
DESA .......................... KECAMATAN ...................
KABUPATEN MANGGARAI BARAT

Hari / Tanggal : ................ / ......... 2021

Tanggal : .......................................
Acara : Penetapan Data SDGS Desa 2021

NO NAMA L/P ALAMAT UNSUR TANDA TANGAN

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NO NAMA L/P ALAMAT UNSUR TANDA TANGAN

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Kepala Desa Ketua BPD

........................................ ........................................
 DAFTAR HADIR
BPD DESA ............................
KECAMATAN ................... KABUPATEN MANGGARAI BARAT

Hari / Tanggal : ................ / ......... 2021

Tanggal : .......................................
Acara : Penetapan Data SDGS Desa 2021
NO NAMA L/P ALAMAT UNSUR TANDA TANGAN

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Ketua BPD

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