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FORMULIR DATA PELAKU USAHA MIKRO/ULTRA MIKRO TERDAMPAK COVID-19

BANTUAN SOSIAL PRODUKTIF (TAHAP II)

Nama Pemilik : .....................................................................................................................

NIK : .....................................................................................................................

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

Nama Usaha : .....................................................................................................................

Lokasi Tempat Usaha : .....................................................................................................................

Periode Mulai Usaha : .....................................................................................................................

Rekening Bank

Nama Bank : .....................................................................................................................

Nomor Rekening : .....................................................................................................................

Tanggal Saldo : .....................................................................................................................

Jumlah Saldo : .....................................................................................................................

Nilai Omzet tiap bulan (Rp) : .....................................................................................................................

Nomor Telepon : .....................................................................................................................

Kelengkapan Berkas:

Fotokopi Kartu Tanda Penduduk (KTP)

Fotokopi Kartu Keluarga (KK)

Fotokopi Buku Rekening Bank sesuai dengan nama Pemohon


(tanggal saldo terakhir minimal bulan Juli 2020, nominal saldo dibawah Rp 2.000.000)

Fotokopi Izin Usaha Mikro Kecil (IUMK) atau Surat Domisili Usaha dari Kelurahan

Foto Produk /Foto Usaha

Pelaku Usaha

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