RT. ............. RW. ..............

Desa ........................... Kecamatan ................................. Kabupaten ...............................

SURAT KETERANGAN PENGANTAR

Nomor : .......................................................................

Yang bertanda tangan di bawah ini :

Nama : ..........................................................................................................................................
Jabatan : Ketua RT. ............./.............
Alamat : ..........................................................................................................................................
..........................................................................................................................................

Menerangkan dengan sesungguhnya bahwa :

Nama Lengkap : ..........................................................................................................................................

Jenis Kelamin : ..........................................................................................................................................
Tempat, Tanggal Lahir : ........................................., ..............................................................................................
NIK : ..........................................................................................................................................
Pekerjaan : ..........................................................................................................................................
Alamat : ..........................................................................................................................................
..........................................................................................................................................
Keperluan : ..........................................................................................................................................
..........................................................................................................................................
Keterangan Lain-lain : ..........................................................................................................................................
..........................................................................................................................................
Berlaku mulai : ................................................... 20… s.d. ………….……………..…… 20…

Demikian Surat Keterangan ini dibuat untuk dapat digunakan seperlunya.

Dibuat di : . ..........................................................
Pada tanggal : ........................................................ 20…

Tanda Tangan Pemegang Ketua RT........./..........

( …………………..………………. ) ( .................................................. )
Nomor : ...........................................................................
Mengetahui :
Ketua RW. ...............

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