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Formulir Prngembalian Taperum Pns

Formulir Prngembalian Taperum Pns

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Dipublikasikan oleh Kang Aden

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Published by: Kang Aden on Mar 09, 2013
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02/15/2014

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Kode Instansi

*
Kode Kota/Kab*
I. IDENTITAS PNS
Nama : ............................................................................................................................................................................................................
NIP :
Instansi Terakhir ............................................................................................................................................................................................................
Alamat Instansi
Jln : ............................................................................................................................................................................................................
Kab/Kota : ............................................................................................................................................................................................................
Provinsi : ............................................................................................................................................................................................................
No. Telp. Kantor : -
II. ALAMAT TERAKHIR PEMOHON
Jln : .................................................................................................................................................. RT/RW /
Kelurahan : ............................................................................................................................................................................................................
Kecamatan : ............................................................................................................................ Kab/Kota : ..................................................
Provinsi : ............................................................................................................................ Kode Pos:
No. Telp. Rumah : -
III DATA BANK PENYALUR
Nomor Rekening Pemohon : ............................................................................................................................................................................................................
Nama Bank : ............................................................................................................................................................................................................
IV. RIWAYAT GOLONGAN
Tanggal Bulan Tahun
TMT : No. SK :
TMT : No. SK :
TMT : No. SK :
TMT : No. SK :
TMT : No. SK :
V. DATA PENSIUN
TMT Pensiun : - - GOL : P S (PS=Pensiun)
No. SK Pensiun : ............................................................................................................................................................................................................
*Wajib diisi oleh BRI
VI. KETERANGAN AHLI WARIS (JIKA PNS MENINGGAL DUNIA)
Nama : ............................................................................................................................................................................................................
No. KTP : ............................................................................................................................................................................................................
Alamat Terakhir
Jln : .................................................................................................................................................. RT/RW /
Kelurahan : ............................................................................................................................................................................................................
Kecamatan : ............................................................................................................................ Kab/Kota : ..................................................
Provinsi : ............................................................................................................................ Kode Pos:
No. Telp : Rumah : - Kantor : -
Hubungan dengan PNS : Istri Suami Anak ...................................
Surat Ket. Hal Waris Nomor : ............................................................................................................................................................................................................
Pernyataan
Apabila dikemudian hari saya memberikan keterangan palsu maka saya bersedia :
1. Mengembalikan uang Taperum-PNS yang saya terima kepada BAPERTARUM-PNS seluruhnya sekaligus lunas dalam 1 (satu) minggu setelah
menerima Surat Pemberitahuan dari BAPERTARUM-PNS;
2. Apabila saya tidak melaksanakan kewajiban sebagaimana dinyatakan dalam butir 1 diatas, maka saya bersedia diproses sesuai dengan
hukum yang berlaku di Negara Kesatuan Republik Indonesia;
Mengetahui, ...........................................................20.....
Kepala BKD/Ka. Biro Keegawaian/Kabag Kepegawaian
FORMULIR PENGEMBALIAN TAPERUM-PNS
Cap/ Tanda Tangan

Cap/ Tanda Tangan .

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