FORMULIR PENGEMBALIAN TAPERUM-PNS

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 :

Istri

Suami

Kantor :
Anak

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

-

Hubungan dengan PNS

:

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

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

Cap/ Tanda Tangan .

Sign up to vote on this title
UsefulNot useful