PEMERINTAH KABUPATEN WONOGIRI

KECAMATAN NGUNTORONADI

KEPALA DESA WONOHARJO

Jl. Raya Wonogiri Pacitan KM 25 57671

SURAT KETERANGAN
NOMOR : ......................
Yang bertanda tangan di bawah ini menerangkan bahwa :
Nama
: ...................................................................................................
Tempat tanggal lahir
: ...................................................................................................
Alamat
: ...................................................................................................
Pekerjaan
: ...................................................................................................
Kewarganegaraan
: ...................................................................................................
Status Perkawinan
: ...................................................................................................
Agama
: ...................................................................................................
No KK
: ...................................................................................................
NIK
: ...................................................................................................
Keperluan
: ...................................................................................................
...................................................................................................
Berlaku mulai
: ........................................................ s/d ....................................
Keterangan lain
: ...................................................................................................
....................................................................................................
Demikianlah surat keterangan ini dibuat dan kepada instansi terkait untuk
memberikan pelayanan seperlunya
Nomor
:.................................
Tanggal
: .................................

Pemegang surat

Mengetahui
Camat Nguntoronadi

Wonoharjo, .................
Kepala Desa Wonoharjo

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