04
KECAMATAN : Cipayung
KELURAHAN : Lubang Buaya
SURAT PENGANTAR
No. .......... /SP/02/08/........../20......
Yang bertanda tangan di bawah ini, Pengurus RT. 002/ RW. 08 Kelurahan Lubang
Buaya Kecamatan Cipayung, dengan ini menyatakan bahwa:
Nama :
...............................................................................................................
Jenis Kelain :
Laki-laki / Perempuan
Tempat/Tgl Lahir :
...............................................................................................................
Pekerjaan :
...............................................................................................................
No. KTP/KK/NIK :
...............................................................................................................
Kewarganegaraan :
Indonesia
Pendidikan :
...............................................................................................................
Agama :
Islam / Kristen / Hindu / Buddha
Alamat :
Lubang Buaya RT. 002 / RW. 08
Maksud/Keperluan :
...............................................................................................................
...............................................................................................................
...............................................................................................................
Nomor : ...........................................
Jakarta, ...............................
Mengetahui,
Ketua RW. 008 Ketua RT. 002 / RW. 008
H. Wawang Yachrudin