PEMERINTAH PROVINSI KHUSUS IBUKOTA JAKARTA

PENGURUS RUKUN TETANGGA 000 / 00

KELURAHAN TEGAL ALUR KECAMATAN KALIDERES
KOTA ADMINISTRASI JAKARTA BARAT
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SURAT PENGANTAR
NO. ...... / ................

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

Nama : Abdul Manan

Jenis Kelamin :Laki-laki
Tempat / Tgl. Lahir : Dusun Kebun Sudak, 03 Januari 1990
No. KTP / KK : .............................................................................................
Kewarganegaraan : ............................................................................................
Agama : .............................................................................................
Alamat : .............................................................................................
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Maksud / keperluan : ............................................................................................
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Nomor : ............................ Jakarta, ..........................

Mengetahui Pengurus RT ....... / ......

Pengurus RW .......
Stempel

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