RUKUN TETANGGA (RT) ___

PERUMAHAN ERAMAS 2000 RW 015

KELURAHAN PULOGEBANG. KECAMATAN CAKUNG
JAKARTA TIMUR, KODE POS 13950

LAMPIRAN XII : Model AA.04

SURAT PENGANTAR
No. ................................

Yang bertanda tangan di bawah ini, Pengurus RT.00__ / RW.015

Kelurahan Pulogebang, Kecamatan Cakung, Jakarta Timur dengan ini menerangkan
bahwa :
Nama :..............................................................................................

Jenis Kelamin :..............................................................................................

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

Pekerjaan :...............................................................................................

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

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

Pendidikan :................................................................................................

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

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

RT..................../ RW......................

Maksud Keperluan :..............................................................................................

...............................................................................................

...............................................................................................

...............................................................................................

Nomor : ............................... Jakarta, .......................................

Mengetahui , Pengurus RT 00__/RW015
Pengurus RW 015 Ketua,

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