SURAT KETERANGAN

Yang bertanda tangan di bawah ini Pengurus RT .... / RW ..... Kelurahan ................. Kecamatan

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Menerangkan bahwa :

Nama : .............................................................................................

Jenis Kelamin : Laki-laki

Tempat / Tgl. Lahir : .............................................................................................

No. KTP / KK : .............................................................................................

Kewarganegaraan : ............................................................................................

Agama : .............................................................................................

Alamat : .............................................................................................

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Maksud / keperluan : ............................................................................................

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Tangerang, ..........................

Pengurus RT

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