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KEMENTERIAN AGAMA

KANTOR KABUPATEN
BLITAR
Jl. A. Yani No. 103 Telp. 0342-801221 Fax. 0342-801381
BLITAR Kode Pos 66131
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SURAT PERNYATAAN TANGGUNG JAWAB


Nomor : Kd.15.31/1/KS.01/ /2015

Yang bertandatangan di bawah ini :

Nama : Drs. H. Akhmad Mubasyir, MA


NIP : 19580423 198103 1 003
Jabatan : Kepala Kankemenag. Kab. Blitar

Dengan ini menyatakan Barang Milik Negara SELAIN tanah dan/atau bangunan dengan
perincian data sebagai berikut:

Jenis BMN SELAIN tanah dan/


No. Nilai Perolehan Kode Barang
Bangunan
1 Lemari Besi/Metal 1,489,363 3050104001
2 Lemari Kayu 5,024,242 3050104002
3 Lemari Kayu 5,024,242 3050104002
4 Lemari Kayu 5,024,242 3050104002
5 Lemari Kayu 3,314,000 3050104002
6 Alat Kantor Lainnya 4,418,263 3050199999
7 Meja Kerja Kayu 4,970,455 3050201002
8 Meja Kerja Kayu 4,970,455 3050201002
9 Meja Kerja Kayu 4,970,455 3050201002
10 Meja Kerja Kayu 4,970,455 3050201002
11 Meja Kerja Kayu 4,970,455 3050201002
12 Meja Komputer 6,515,000 3050201009
13 Meja Komputer 5,570,000 3050201009
14 Meja Komputer 5,570,000 3050201009
15 Meja Komputer 5,570,000 3050201009
16 Meja Komputer 5,570,000 3050201009
17 Meja Komputer 5,570,000 3050201009
18 Meja Komputer 5,570,000 3050201009
19 Meja Komputer 221,000 3050201009
20 Meja Komputer 221,000 3050201009
Finger Printer Time and Attandance Acces Control
21 System 3,225,700 3060207005
Finger Printer Time and Attandance Acces Control
22 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
23 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
24 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
25 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
26 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
27 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
28 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
29 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
30 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
31 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
32 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
33 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
34 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
35 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
36 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
37 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
38 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
39 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
40 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
41 System 2,225,700 3060207005
Finger Printer Time and Attandance Acces Control
42 System 2,225,700 3060207005
43 Kursi Dorong 1,105,000 3070101127
44 Kursi Dorong 442,000 3070101127
45 Kursi Dorong 442,000 3070101127
46 Kursi Dorong 442,000 3070101127
47 Kursi Dorong 442,000 3070101127
48 P.C Unit 9,975,000 3100102001
49 P.C Unit 9,975,000 3100102001
50 P.C Unit 9,975,000 3100102001
51 P.C Unit 9,975,000 3100102001
52 P.C Unit 11,875,000 3100102001
53 Note Book 8,284,000 3100102003
54 Note Book 4,031,600 3100102003
55 Note Book 8,284,000 3100102003
56 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
57 Printer (Peralatan Personal Komputer) 750,000 3100203003
58 Printer (Peralatan Personal Komputer) 750,000 3100203003
59 Printer (Peralatan Personal Komputer) 1,215,000 3100203003
60 Printer (Peralatan Personal Komputer) 718,000 3100203003
61 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
62 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
63 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
64 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
65 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
66 Printer (Peralatan Personal Komputer) 8,125,000 3100203003
67 Printer (Peralatan Personal Komputer) 750,000 3100203003
68 Printer (Peralatan Personal Komputer) 750,000 3100203003
69 Scanner (Peralatan Personal Komputer) 828,500 3100203004
70 Server 21,428,000 3100204001
Total Perolehan : Rp. 298,801,126

Adalah Barang Milik Negara yang dikuasai dan digunakan untuk penyelenggaraan tugas dan
fungsi Kantor Kementerian Agama Kabupaten Blitar / Bimas Islam (299098).

Demikian pernyataan ini kami buat dengan sebenar-benarnya dalam rangka permohonan
penetapan status penggunaan Barang Milik Negara.

Blitar, 26 Mei 2015


Kepala,

Drs. H. Akhmad Mubasyir, MA


NIP. 195804231981031003