SURAT PERNYATAAN KEPEMILIKAN TANAH

Yang b e rta n d a ta n g a n d ibaw ah i n i :

N a m a : ........................................

U m ur : .......................................

Jenis K elam in : .......................................

A la m a t : ........................ ...............

M en y atak an den g an sebenarny a b a h w a tan ah d e n g an d ata-d ata sebagai b e r ik u t:

Jalan /B an jar/S u b ak : ...................................................................................................................

NOP : ..................................................................................................................

D esa/K elu rah an : ..................................................................... .............................................

K ecam atan : ........... ............................................................... .......................................

K a b u p a te n /K o ta : ...................................................................................................................

L u a s (m 2) : ...................................................................................................................

A d a lah b e n ar m ilik d a r i ............................................................... D an tid a k d alam sen g k eta d e n g an p ih a k lain.

D em ik ian p e m y a ta a n ini d ib u a t d e n g an p e n u h k esad aran d a n ra sa tan g g u n g ja w a b serta tid a k a d a

te k an an /p ak saan dari p ih a k m a n a p u n u n tu k d a p at d ip ergunakan seb ag ai d a ta p e n d u k u n g p ro ses
p en etap a n W ajib P a ja k atas o b y ek p a ja k y an g d iseb u t diatas d an h a n y a dap at dim an faatk an u n tu k
k e p en tin g an p en erb itan S urat P e m b eritah u an P a ja k T erhutang (S PPT ). A p ab ila d ik em u d ian hari
te m y a ta p e m y a ta a n ini tid a k b en ar/ad a k esalahan, say a b e rsed ia d itu n tu t d ih a d a p an p ih a k -p ih a k y an g
b erw en an g b aik sec a ra p id an a m a u p u n p e rd a ta d an m e m p e rtan g g u n g jaw ab k an n y a di d ep an p e n g ad ilan
serta tid a k m e lib atk an P em erin tah K a b u p ate n B uleleng / B adan K e u an g a n D aerah K ab u p aten B uleleng.

M e n g e ta h u i: S ingaraja,

K e p ala D u su n / S ubak / K e p ala L ingkungan, Y ang m e n b u a t pem y ataan ,

Materai
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 SURAT KETERANGAN KEPEMILXKAN TANAH
N o. : .....................................................................

T anggal : ....................................................................

Yang b erta n d a ta n g a n d ib a w ah i n i :

N am a : .....................................

A ia m a t : ......................................

Jab atan : K e p a la D e sa /L u rah

D engan ini m en eran g k an b a h w a :

N am a

A ia m a t

U m ur

M em ang b e n ar m em ilik i/m em an faatk an *) O b yek P a ja k d e n g a n :

N o m o rO b y e k P a ja k : .................................................................................................................................. ........

L o k asi : ...........................................................................................................................................

L uas T anah : ............ .......... ..................................................................................................................

D em ik ian pern y ataan ini d ib u a t d e n g an se b e n a m y a d a n ra s a tan g g u n g ja w a b dan h a n y a dapat

d im an faatk an u n tu k k e p en tin g an p e n erb ita n S u rat P em b e rita h u a n P a ja k T erhutang (S P P T )

A p a b ila d ik em u d ian hari te rn y a ta p e rn y a taa n ini tid a k b en ar/ad a kesalah an , k am i bersed ia d itu n tu t
d i h a d a p a n p i h a k - p i h a k y a n g b e r w e n a n g b a ik s e c a r a p i d a n a m a u p u n p e r d a t a d a n
m em p ertan g g u n g jaw ab k an n y a di d e p an p e n g a d ila n se rta tid a k m e lib atk an P e m e rin ta h K ab u p aten
B u lelen g /B ad an K eu an g an D aerah K a b u p ate n B u lelen g

Y ang m en eran g k an
K e p ala D e sa / L u rah

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*) c o re t y a n g tid a k p e rlu