SKPD : ...........................................

SURAT TANDA SETORAN

STS No :...........................................................................

Kepada :
......................................
......................................
Di -
......................................

Harap diterima uang setoran sebesar : Rp. ............................................................

(dengan huruf ) ...................................................................................

...................................................................................
Penerimaan

Kode Rekening Uraian Rincian Obyek Jumlah

TOTAL

(...........................................) (...........................................) (...........................................) (...........................................)

NIP. ..................................... NIP. ..................................... NIP. ..................................... NIP. .....................................

Malang,
Uang tersebut diterima oleh :