Lampiran 1

FORMULIR VERIFIKASI PNSD KAB.PIDIE DAN ANGGOTA KELUARGA

KAB/ KOTA KDSATKER NAMA SATKER

KAB. ACEH BESAR 51010021070500 SMK NEGERI PENERBANGAN ACEH, KAB. ACEH BESAR
Ket. Hub. Keluarga P= PNS, I=Istri, S=suami, A=Anak, T=Tanggungan lain
NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. KEPENDUDUKAN NIPLAMA NIPBARU NAMA TGL. LAHIR Nama Faskes Tingkat I
JKN-KIS KELUARGA PILIH SALAH SATU)
(NIK)
1 00000001222222 1171045204890002 12222222222222 122222 LISASAUMI RAHMATNA PESERTA 12/04/1989 BATOH
2 00000001222223 1171045204890002 12222222222222 122222 AGUNG DESTIAWARMAN PESERTA 30/12/1986 LHOKNGA
3 00000001222224 1171045204890002 12222222222222 122222 LENA MAYDA ULFIA ISTRI 27/02/1990 LHOKNGA
4 00000001222225 1171045204890002 12222222222222 122222 ZHAFIF AL FATIH ANAK 19/07/2014 LHOKNGA
5 00000001222226 1171045204890002 12222222222222 122222 ANDHIKA SATRIA PESERTA 16/03/1993 LHOKNGA
6 00000001222227 1171045204890002 12222222222222 122222 ARMIA PESERTA 23/04/1988 LAMPISANG
7 00000001222228 1171045204890002 12222222222222 122222 PUTRI RAHMI ISTRI 01/01/1993 LAMPISANG
DATA DIPILIH PADA SUDUT KANAN KOLOM
8 00000001222229 1171045204890002 12222222222222 122222 MAULIDYA PUTRI ARMIA ANAK 21/01/2017 LAMPISANG (TIDAK DIISI MANUAL), dengan pilihan :
9 00000001222230 1171045204890002 12222222222222 122222 HUMAIRA PUTRI ARMIA ANAK 09/04/2018 LAMPISANG Data Sesuai, atau
10 00000001222231 1171045204890002 12222222222222 122222 MARINI PESERTA 28/07/1978 MEURAXA PNS pindah satker, atau
PNS sudah pensiun/ meninggal/ mengundurkan diri, atau
11 Bukan PNS pada satker kami.
12
25

Banda Aceh, .... Juli 2020

Pimpinan Satuan Kerja
stempel
satker

DATA TIDAK DILAKUKAN PERUBAHAN DAN DITAMBAH = =

Pembina
NIP.......

Page 1 of 15
Data Sesuai
PNS pindah satker
PNS sudah pensiun/ meninggal/ mengundurkan diri
Bukan PNS pada satker kami
 FORMULIR VERIFIKASI PNSD KAB.PIDIE DAN ANGGOTA KELUARGA

KAB/ KOTA KDSATKER NAMA SATKER

KAB. PIDIE 00000003803926 DINAS PERTANIAN DAN PANGAN KABUPATEN PIDIE
Ket. Hub. Keluarga P= PNS, I=Istri, S=suami, A=Anak, T=Tanggungan lain
NOMOR INDUK
NO. NOMOR KARTU KEPENDUDUKAN NIPLAMA NIPBARU NAMA HUB. TGL. LAHIR Nama Faskes Tingkat I KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
JKN-KIS KELUARGA PILIH SALAH SATU)
(NIK)
1 0000000401657 1107161710640001 390023422 196410172003121002 A. HANIFAH PESERTA 17/10/1964 KLINIK MUTIARA
2 0001115171752 1107160312040001 390023422 196410172003121002 M. ZAKI RABBANI ANAK 03/12/2004 PIDIE
3 0001383264707 1107165107140002 390023422 196410172003121002 AMIRATU ZAKYYA ANAK 11/07/2014 PIDIE
4 0000000401782 1107092104720001 390014239 197204211999031005 ADI KURNIA PESERTA 21/04/1972 KOTA SIGLI
5 0000000401793 1107096612800002 390014239 197204211999031005 RIZA KUSUMA ISTRI 26/12/1980 KOTA SIGLI
6 0000168211438 1107091806050002 390014239 197204211999031005 M. RAIS RIVALDI ANAK 18/06/2005 KOTA SIGLI
7 0001114280469 1107090312060001 390014239 197204211999031005 M RIZKI RIVALDI ANAK 03/12/2006 KOTA SIGLI
8 0000000401804 1107092609010001 390014239 197204211999031005 M. ROZAN RIVALDI ANAK 26/09/2001 KOTA SIGLI
9 0000000401859 1107121706680001 080128844 196806172000031006 ASNAWI PESERTA 17/06/1968 MUARA TIGA
10 0000000401861 1107124202730001 080128844 196806172000031006 YUSNIDAR ISTRI 02/02/1973 MUARA TIGA
11 0002434834473 1107126312110001 080128844 196806172000031006 ZAHRATUN ULFA ANAK 23/12/2011 MUARA TIGA
12 0001115460257 1107126303000001 080128844 196806172000031006 ASNIDAR RAHMAH ANAK 23/03/2000 MUARA TIGA
13 0000000402063 1107092712600001 080098722 196012271989031003 FAKHRUDDIN PESERTA 27/12/1960 KOTA SIGLI
14 0001891896693 1107092607020002 080098722 196012271989031003 MUHAMMAD ASSYIF FATHIA ANAK 26/07/2002 KOTA SIGLI
15 0001890190181 1107094110040001 080098722 196012271989031003 SITI NAJWA FATHIA ANAK 01/10/2004 KOTA SIGLI
16 0000000402107 1107174501620001 390011214 196201051988032005 FARIDAH PESERTA 05/01/1962 SAKTI
17 0000168210257 1107170107580241 390011214 196201051988032005 IBRAHIM BENSEH SUAMI 01/07/1958 SAKTI
18 0001883707042 1107170108990002 390011214 196201051988032005 AULIA RAHMAD ANAK 01/08/1999 SAKTI
19 0000000402142 1107177112690017 390012112 196912311992032007 FATIMAH PESERTA 31/12/1969 KLINIK MUTIARA
20 0000000402153 1107173112640001 390012112 196912311992032007 M DAUD ALI SUAMI 31/12/1964 KLINIK MUTIARA
21 0001110722804 1107171101050001 390012112 196912311992032007 M. AIMAN AQILMULLAH ANAK 11/01/2005 SAKTI
22 0001451545424 1107176206020001 390012112 196912311992032007 NURUL 'ALA ANAK 22/06/2002 KLINIK MUTIARA
23 0000000402491 1107167112640051 080127975 196412311999032010 MAULIDA PESERTA 31/12/1964 KLINIK MUTIARA
24 0000000403086 1107170607680002 390013081 196807061994031011 MUHAMMADDIAH PESERTA 06/07/1968 KLINIK BUNDA
25 0000000403492 1107096101650003 050047087 196501211985022001 SUMIYATI PESERTA 21/01/1965 KLINIK MUTIARA
26 0000000403503 1107090107590133 050047087 196501211985022001 AIYUB DAUD SUAMI 01/07/1959 KLINIK MUTIARA
27 0000000404379 1107121506740001 X09109752 197406152009031003 SUPRIADI PESERTA 15/06/1974 KOTA SIGLI
28 0001889563544 1107096111120001 X09109752 197406152009031003 RAISA SAUSAN NAJLA ANAK 21/11/2012 KOTA SIGLI
29 0002089951997 1107090210160002 X09109752 197406152009031003 MUHAMMAD ALTHAF RAFANDA ANAK 02/10/2016 KOTA SIGLI
30 0000000408093 1107240205620001 080067502 196205251983031026 ABDULLAH A SALAM PESERTA 02/05/1962 KLINIK MUTIARA
31 0000000408104 1107247112680023 080067502 196205251983031026 SAFRINA ISTRI 31/12/1968 MUTIARA TIMUR
32 0000170968825 1107244110090001 080067502 196205251983031026 AMANDA ANAK 01/10/2009 KLINIK MUTIARA
33 0002932063143 1107241612990002 080067502 196205251983031026 ARIF FADILLAH ANAK 16/12/1999 KLINIK MUTIARA
34 0000000408306 1107096602740003 390019599 197402262002122002 CUT PUSPA MURNI PESERTA 26/02/1974 KOTA SIGLI
35 0000000408317 1107091504730002 390019599 197402262002122002 MUHAMMAD JUNAIDI SUAMI 15/04/1973 KOTA SIGLI
36 0000000408339 1107090807030002 390019599 197402262002122002 MAULANA AKBAR ANAK 08/07/2003 KOTA SIGLI
37 0000000408328 1107094312000002 390019599 197402262002122002 SUCI SAUFA YUTHIKA ANAK 03/12/2000 KOTA SIGLI
38 0001801711967 1107095906070003 390019599 197402262002122002 FINANDA ZULFA ANAK 19/06/2007 KOTA SIGLI
39 0000000408734 1107175006780001 390016062 197806102000102001 HUSNITA PESERTA 10/06/1978 SAKTI
40 0000194736341 1107170404740001 390016062 197806102000102001 T MASKUR SUAMI 04/04/1974 SAKTI
41 0002911014729 1107170412180001 390016062 197806102000102001 T MUHAMMAD AZKA ANAK 04/12/2018 SAKTI
42 0000211131055 1107172007110001 390016062 197806102000102001 T M RAYYAN AL FATIH ANAK 20/07/2011 SAKTI
43 0000977102651 1107176306120001 390016062 197806102000102001 CUT RAHIL FAHIRA ANAK 23/06/2012 SAKTI
44 0000000409263 1107250204660001 390011769 196604021990031006 MAHDI PESERTA 02/04/1966 KLINIK MUTIARA
45 0000000409274 1107254112730001 390011769 196604021990031006 KASNIDAR ISTRI 12/01/1973 KLINIK MUTIARA
46 0000000409296 1107256607000001 390011769 196604021990031006 WILDA SANIATI ANAK 26/07/2000 KLINIK MUTIARA
47 0001793406622 1107256804040001 390011769 196604021990031006 NISWATIL ASRA ANAK 28/04/2004 KLINIK MUTIARA

Page 3 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
48 0001786533052 1107251709060001 390011769 196604021990031006 SYAHRIL MAHYUDA ANAK 17/09/2006 KLINIK MUTIARA
49 0000000409645 1107137112730013 390012632 197312311993032003 NURLAILA PESERTA 31/12/1973 KLINIK MUTIARA
50 0000000409689 1107093112630015 080116289 NYAK GADE PESERTA 31/12/1963 KOTA SIGLI
51 0000000436364 X09109806 197009152009031001 SULAIMAN PESERTA 15/09/1970 GLUMPANG BARO
52 0000000466211 1107273112630001 080131635 196312312002121032 ABDULLAH PESERTA 31/12/1963 KLINIK MUTIARA
53 0000000466233 1107277112680002 080131635 196312312002121032 NURAINI ISTRI 31/12/1968 KLINIK MUTIARA
54 0001112798035 1107270206020001 080131635 196312312002121032 MAULIDAR ANAK 02/06/2002 MANE
55 0000000466266 1107120201680002 080131656 196801022002121002 ABUBAKAR PESERTA 02/01/1968 MUARA TIGA
56 0000209619382 1107125602810002 080131656 196801022002121002 NURBAITI ISTRI 16/02/1981 MUARA TIGA
57 0002899945877 1107126010040002 080131656 196801022002121002 MAYSAHRAH ANAK 20/10/2004 MUARA TIGA
58 0001115558739 1107121307080001 080131656 196801022002121002 MUHAMMAD SYUKRAN AB ANAK 13/07/2008 MUARA TIGA
59 0002454737387 1107125811130001 080131656 196801022002121002 NAJLA HUMAYRA AB ANAK 18/11/2013 MUARA TIGA
60 0000000466288 1107091012620003 080132277 196212102002121002 ABUBAKAR PESERTA 10/12/1962 KOTA SIGLI
61 0000000466299 1107094605720001 080132277 196212102002121002 MARIANI ISTRI 06/05/1972 KOTA SIGLI
62 0001114774762 1107092306100001 080132277 196212102002121002 MUHAMMAD ADAM RIZKI ANAK 23/06/2010 KOTA SIGLI
63 0001382394666 1107094209000001 080132277 196212102002121002 GEBRINA ANAK 02/09/2000 KOTA SIGLI
64 0000000466479 1107163112650002 390052771 196512312007011048 AMBIA PESERTA 31/12/1965 KLINIK MUTIARA
65 0000164185277 1107175408740001 390052771 196512312007011048 KHATIJAH ISTRI 14/08/1974 KLINIK MUTIARA
66 0000000466593 1107165401690001 390052626 196901142007012002 ANUM JAUHARI PESERTA 14/01/1969 KLINIK MUTIARA
67 0000000466659 1107301007680001 390045339 196807102006041002 ARMIA PESERTA 10/07/1968 PADANG TIJI
68 0001786822356 1107144111750002 390045339 196807102006041002 MARLINA ISTRI 01/11/1975 PADANG TIJI
69 0002472684467 390045339 196807102006041002 MUHAMMAD SALKA MALHEFI ANAK 28/03/2016 PADANG TIJI
70 0000000466795 1107160107690399 390043215 196912312006041046 BAKHTIAR PESERTA 31/12/1969 PIDIE
71 0000000466806 1107164705710002 390043215 196912312006041046 LAIMINA ISTRI 07/05/1971 PIDIE
72 0001115137787 1107160308080004 390043215 196912312006041046 NOUVAL NAZIRA ANAK 03/08/2008 PIDIE
73 0002919324194 1107163004010003 390043215 196912312006041046 RIZKI RAHMADSYAH ANAK 30/04/2001 PIDIE
74 0002919324071 1107160506050007 390043215 196912312006041046 ANANDA FUAD FANTONI ANAK 05/06/2005 PIDIE
75 0000000466907 1107064205680001 390056969 196805022007012004 CUT HANIFAH PESERTA 02/05/1968 KLINIK MUTIARA
76 0000000466931 1107094105720002 390043223 197205012006042023 DARWISAH PESERTA 01/05/1972 KLINIK MUTIARA
77 0000000466997 1107171307640001 080087918 196407131987091001 HAMDANI PESERTA 13/07/1964 SAKTI
78 0000000467008 1107177008690001 080087918 196407131987091001 NURLINAWATI ISTRI 30/08/1969 SAKTI
79 0002223559991 1107173005030001 080087918 196407131987091001 HAFIQ ALFARKI ANAK 30/05/2003 SAKTI
80 0002223560621 1107174803100001 080087918 196407131987091001 AMIRA ANAK 08/03/2010 SAKTI
81 0000000467076 1107093112710013 710028763 HASBALLAH PESERTA 31/12/1971 KOTA SIGLI
82 0001299259631 1107095408090001 710028763 RAUDHATUL RAHMI ANAK 14/08/2009 KOTA SIGLI
83 0000977985077 1107096801010001 710028763 KHAIRUN NISA ANAK 28/01/2001 KOTA SIGLI
84 0000977985145 1107091405040001 710028763 SABILIL HAQ ANAK 14/05/2004 KOTA SIGLI
85 0000000467155 1107091702680001 390023904 196802172003121001 IR HUSAINI PESERTA 17/02/1968 KLINIK MUTIARA
86 0000166148065 1107094708680002 390023904 196802172003121001 ERLINA ISTRI 07/08/1968 KLINIK MUTIARA
87 0000166148346 1107090510000002 390023904 196802172003121001 RANDY MAULANA ANAK 05/10/2000 KLINIK MUTIARA
88 0001894286632 1107091405060001 390023904 196802172003121001 RYAN ARDIANSYAH ANAK 14/05/2006 KLINIK MUTIARA
89 0000000467166 1107160110670002 390043226 196710012006041010 HUSIN PESERTA 01/10/1967 KLINIK MUTIARA
90 0000000467177 1107164211700002 390043226 196710012006041010 SYARIFAH ISTRI 02/11/1970 KLINIK MUTIARA
91 0001115189796 1107166209990003 390043226 196710012006041010 NILAWATI ANAK 22/09/1999 KLINIK MUTIARA
92 0000000467201 1107166307630002 390012838 196307231994022002 HUSNA PESERTA 23/07/1963 KOTA SIGLI
93 0000000467212 1107161312620001 390012838 196307231994022002 SAGIRAN SUAMI 13/12/1962 KOTA SIGLI
94 0001113273213 1107161811000003 390012838 196307231994022002 DIAN NOFRIADI ANAK 18/11/2000 KOTA SIGLI
95 0000000467324 1107073112630020 390043209 196312312006041043 ADMI PESERTA 31/12/1963 KLINIK MUTIARA
96 0001115312027 1107075712080001 390043209 196312312006041043 NEIVA BADRISHIYA ANAK 17/12/2008 KLINIK MUTIARA
97 0000000467414 1107123112640005 390043210 196412312006041039 ZULKIFLI PESERTA 31/12/1964 MUARA TIGA
98 0000000467447 1107122404020001 390043210 196412312006041039 AZZUL AYYA ANAK 24/04/2002 MUARA TIGA
99 0000000467436 1107123009990001 390043210 196412312006041039 AFZALUL HANIF ANAK 30/09/1999 MUARA TIGA

Page 4 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
100 0000000467471 1107067112690011 390055858 196912312007012307 SUFITAH PESERTA 31/12/1969 KOTA SIGLI
101 0001804959641 1107061110510001 390055858 196912312007012307 CHAIRUDDIN RISYAD SUAMI 11/10/1951 KOTA SIGLI
102 0001382269937 1107067105030001 390055858 196912312007012307 NAZWA MEYLIA ANAK 31/05/2003 KOTA SIGLI
103 0000194135613 1107062304010001 390055858 196912312007012307 MUAMMAR CHALIS ANAK 23/04/2001 KOTA SIGLI
104 0000000467482 1107163112630052 080132057 196312312002121028 ISKANDAR PESERTA 31/12/1963 KOTA SIGLI
105 0000163575145 1107164304670003 080132057 196312312002121028 NURMAWATI ISTRI 03/04/1967 KOTA SIGLI
106 0001112303452 1107162202060002 080132057 196312312002121028 MUHIBBUL ANAK 22/02/2006 KOTA SIGLI
107 0000000467583 1107121205770002 390055793 197705122007011002 JAMALUDDIN PESERTA 12/05/1977 MUARA TIGA
108 0002050511927 1107124804160001 390055793 197705122007011002 RISKA SYAKIRA GHINA ANAK 08/04/2016 MUARA TIGA
109 0001868033305 1107126905050001 390055793 197705122007011002 DARA FADHLATUL GHINA ANAK 29/05/2005 MUARA TIGA
110 0001868034734 1107121904090002 390055793 197705122007011002 HILVAN RAJASA ANAK 19/04/2009 MUARA TIGA
111 0000000468088 1107066306680001 390013917 196806231998032001 MARDHIAH PESERTA 23/06/1968 TEUPIN RAYA
112 0000000468325 1107303112630005 080132058 196312312002121029 MUHAMMAD YUNUS PESERTA 31/12/1963 GLUMPANG BARO
113 0000211065456 1107305409730001 080132058 196312312002121029 NURJANNAH ISTRI 19/09/1973 GLUMPANG BARO
114 0001115335596 1107306409020001 080132058 196312312002121029 YAUMI AIDA ANAK 24/09/2002 GLUMPANG BARO
115 0000000468437 1107173112670014 390020922 196712312002121021 MUSLEM PESERTA 31/12/1967 SAKTI
116 0000202110232 1107174810680001 390020922 196712312002121021 NURMI ISTRI 08/10/1968 SAKTI
117 0000202110434 1107170711000001 390020922 196712312002121021 IRFAN MAULANA ANAK 07/11/2000 SAKTI
118 0002478862719 1107172609060001 390020922 196712312002121021 AKBAR MAULANA ANAK 26/09/2006 SAKTI
119 0000000468663 1107091007720001 710032664 197207102000031006 SAIFUL BAHRI PESERTA 10/07/1972 KOTA SIGLI
120 0000000468674 1107094407810002 710032664 197207102000031006 MEUTIA ISTRI 04/07/1981 KOTA SIGLI
121 0001115978747 1107095508070001 710032664 197207102000031006 SYIFA AILA MUNISA ANAK 15/08/2007 KOTA SIGLI
122 0002197546953 1107094209110001 710032664 197207102000031006 SAFA AZWA MADINA ANAK 02/09/2011 KOTA SIGLI
123 0000000468685 1107095102710002 390055792 197102112007012003 SAMSIMAR PESERTA 11/02/1971 KLINIK MUTIARA
124 0000208718166 1107091505690003 390055792 197102112007012003 JUFRI SUAMI 15/05/1969 KLINIK MUTIARA
125 0000000468696 1107150807680001 390052630 196807082007011004 SAMSUL BAHRI SP PESERTA 08/07/1968 BP AA MEDICAL
126 0000000468718 1107156002740001 390052630 196807082007011004 EKAPURI RAHYUNI SE ISTRI 20/02/1974 PEUKAN BARO
127 0000000468729 1107155005050002 390052630 196807082007011004 RIZKI MAULIDIA ANAK 10/05/2005 PEUKAN BARO
128 0000000468731 1107191104580001 390043798 196404112006041001 SARIMAULIDIN PESERTA 11/04/1964 PIDIE
129 0000000468742 1107095809700001 390013396 197009181996032001 SARMADIANTI PESERTA 18/09/1970 KLINIK MUTIARA
130 0000000468753 1107091311640001 390013396 197009181996032001 ISWAN SUAMI 13/11/1964 KLINIK MUTIARA
131 0000000468764 1107095104000001 390013396 197009181996032001 RINI KHAIRUNI ANAK 11/04/2000 KLINIK MUTIARA
132 0000000468775 1107093012020003 390013396 197009181996032001 MUHAMMAD FADHLY FAHREZI ANAK 30/12/2002 KLINIK MUTIARA
133 0000000468933 1107177112630019 080122743 196312311998032010 SURYANA PESERTA 31/12/1963 SAKTI
134 0000000469135 1107176504690002 080132054 196904252002122001 USMARIATI PESERTA 25/04/1969 KLINIK BUNDA
135 0000195150712 1107171010640001 080132054 196904252002122001 ISMAIL UBIT SUAMI 10/10/1964 KLINIK BUNDA
136 0002061281845 1107174904060001 080132054 196904252002122001 MAGFIRAH ANAK 09/04/2006 SAKTI
137 0001110842403 1107171512000002 080132054 196904252002122001 SAIDUL AULIA ANAK 15/12/2000 SAKTI
138 0001110842458 1107176102080001 080132054 196904252002122001 MUNAWARAH ANAK 21/02/2008 SAKTI
139 0000000469258 1107150709730001 390013777 197309071997031002 ZULFIKAR PESERTA 07/09/1973 KOTA SIGLI
140 0001790022756 1107161206140001 390013777 197309071997031002 BARIQ KHALAF MAHDI ANAK 12/06/2014 KOTA SIGLI
141 0000000469348 1107091708700001 X09109654 197008172009031001 HASAN BASRI PESERTA 17/08/1970 KLINIK MUTIARA
142 0000199063484 1107096104740001 X09109654 197008172009031001 MUTIA ISTRI 21/04/1974 KLINIK MUTIARA
143 0000199063721 1107094905060001 X09109654 197008172009031001 SITI NURFAIZAH ANAK 09/05/2006 KLINIK MUTIARA
144 0000199063585 1107097105010001 X09109654 197008172009031001 SITI BAIZUHRA ANAK 31/05/2001 KLINIK MUTIARA
145 0001790886137 1107094909090002 X09109654 197008172009031001 SITI SHAFIRA ANAK 09/09/2009 KLINIK MUTIARA
146 0000000472746 1107072812740001 X09110505 197412282009031001 TEUKU HAFNI PESERTA 28/12/1974 PEUKAN BARO
147 0002214565007 1107156608150001 X09110505 197412282009031001 CUT NAFISA HANUM ANAK 26/08/2015 PEUKAN BARO
148 0000207690625 1107150808110001 X09110505 197412282009031001 TEUKU DZAKY MUBARAK ANAK 08/08/2011 PEUKAN BARO
149 0000000472869 1107174202810003 X09188752 198102022009042004 ZURAIDA PESERTA 02/02/1981 SAKTI
150 0001263854507 1107170507760003 X09188752 198102022009042004 MAIMUN SUAMI 02/09/1974 SAKTI
151 0002448997918 1107173105170001 X09188752 198102022009042004 MAULANA RIZKI ANAK 31/05/2017 SAKTI

Page 5 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
152 0001866638654 1107174411140003 X09188752 198102022009042004 FAIZAH ALYA AZIZA ANAK 04/11/2014 SAKTI
153 0000000479755 1107061612650001 080093326 196512161988031002 ABDUL GANI IBRAHIM PESERTA 16/12/1965 BANDAR BARU
154 0001844048957 1107061512030001 080093326 196512161988031002 MUNAZAR SAPUTRA ANAK 15/12/2003 BANDAR BARU
155 0000000479788 1107090501700001 390045542 197001052006041003 AKMAL PESERTA 05/01/1970 KOTA SIGLI
156 0000000479799 1107094610700001 390045542 197001052006041003 EPIANA ISTRI 06/10/1970 KOTA SIGLI
157 0000000479801 1107091102030001 390045542 197001052006041003 AKFI FUADI CHALIS ANAK 11/02/2003 KOTA SIGLI
158 0000000479812 1107090411040001 390045542 197001052006041003 NAUVAL GHUFRAN ANAK 04/11/2004 KOTA SIGLI
159 0000000479823 1107184504660001 080108631 196604051992032007 ANIDAR PESERTA 05/04/1966 KLINIK MUTIARA
160 0000000479845 1107180107990066 080108631 196604051992032007 YUSNANDAR ANAK 05/10/1999 KLINIK MUTIARA
161 0000000479856 1107180107020034 080108631 196604051992032007 MUHAMMAD NURMAHDI ANAK 23/05/2002 KLINIK MUTIARA
162 0001115012092 1107184603090001 080108631 196604051992032007 NABILA PUTRI ANAK 06/03/2009 KLINIK MUTIARA
163 0000000479891 1107096003640001 080091084 196403201987112001 ASTIWARNI PESERTA 20/03/1964 KLINIK MUTIARA
164 0000000479968 1107177112720027 390036893 197212312006042008 CUT ROSNANIAH PESERTA 31/12/1972 SAKTI
165 0001885207959 1107174907140001 390036893 197212312006042008 RIZKA ANNIDA ANAK 09/07/2014 SAKTI
166 0000000479981 1107165405720002 390042392 197205142006042004 ELLYZAR PESERTA 14/05/1972 KLINIK MUTIARA
167 0000000479992 1107095205700001 390043218 197005122006042004 FAUZIAH PESERTA 12/05/1970 MUTIARA BARAT
168 0001907200664 1107094808070003 390043218 197005122006042004 ASSYIFA TARCHA ANAK 08/08/2007 MUTIARA BARAT
169 0000000480058 1107146804700001 390043205 197004282006042002 HUSNA PESERTA 28/04/1970 PADANG TIJI
170 0000000480069 1107141103660001 390043205 197004282006042002 SYAMSUL BAHRI SUAMI 11/03/1966 PADANG TIJI
171 0002204462957 1107143007990002 390043205 197004282006042002 ZUL FAHMI ANAK 30/07/1999 PADANG TIJI
172 0000000480161 1107065206700001 390020920 197006122002122012 IRDAWATI PESERTA 12/06/1970 TEUPIN RAYA
173 0001092982195 1107061503640001 390020920 197006122002122012 ASNAWI SUAMI 15/03/1964 TEUPIN RAYA
174 0002213370898 1107061808090002 390020920 197006122002122012 FAIZ ALFATIR ANAK 18/08/2009 TEUPIN RAYA
175 0002213370786 1107066603020001 390020920 197006122002122012 VINNA ANNISA ANAK 26/03/2002 TEUPIN RAYA
176 0000000480194 1107031206660002 080112902 196606121993031008 ISMANUDDIN PESERTA 12/06/1966 BATEE
177 0000000480205 1107034301730004 080112902 196606121993031008 PUTEH DI ISTRI 03/01/1973 BATEE
178 0001429407371 1107036504010002 080112902 196606121993031008 ZAITUN MUNAR ANAK 25/04/2001 BATEE
179 0000000480295 1107166411690003 080127970 196911241999032001 JULINDA PESERTA 24/11/1969 KLINIK MUTIARA
180 0000000480306 1107166712770001 390039204 197712272006042002 KHAIRIAH MUHAMMAD PESERTA 27/12/1977 PIDIE
181 0000000480317 1107160712750001 390039204 197712272006042002 MULIADI SUAMI 07/12/1975 PIDIE
182 0000194275631 1107166111090001 390039204 197712272006042002 SYAFIA AZ ZAHRA ANAK 21/11/2009 PIDIE
183 0000194275517 1107166905080001 390039204 197712272006042002 FATHIA SABRINA ANAK 29/05/2008 PIDIE
184 0001483455925 1107160711140001 390039204 197712272006042002 SULTHAN AHMAD ZAKI ANAK 07/11/2014 PIDIE
185 0000000480328 1107180810610001 080073448 196110081986051001 M AMIN PESERTA 08/10/1961 SIMPANG TIGA (PIDIE)
186 0000000480341 1107187112670007 080073448 196110081986051001 RAIHAN ISTRI 31/12/1967 SIMPANG TIGA (PIDIE)
187 0000000480363 080059651 196112311983031077 MANSUR PESERTA 31/12/1961 KLINIK BUNDA
188 0000000480374 080059651 196112311983031077 NURLAILA ISTRI 31/12/1968 KLINIK BUNDA
189 0000000480396 1107305809750001 390023423 197509182003122002 MARLINA PESERTA 18/09/1975 GLUMPANG BARO
190 0001880416359 1107150304830001 390023423 197509182003122002 FADLIADI SUAMI 03/04/1983 GLUMPANG BARO
191 0002043444418 1107302712150001 390023423 197509182003122002 MUHAMMAD FHONNA ANAK 27/12/2015 GLUMPANG BARO
192 0000000480407 1107157112680010 390043217 MASRIYAH PESERTA 31/12/1968 PEUKAN BARO
193 0000173804499 1107150402610001 390043217 M. YUNUS SUAMI 04/02/1961 PEUKAN BARO
194 0001893257998 1107154712010001 390043217 MAGHFIRAH ANAK 07/12/2001 PEUKAN BARO
195 0002769342118 1107156712060002 390043217 NURAIDA ANAK 27/12/2006 PEUKAN BARO
196 0002911133103 1107155411040002 390043217 NURUL FITRI ANAK 14/11/2004 PEUKAN BARO
197 0000000480418 1107177112740017 390039206 197404162006042005 MILLISSA'ADAH PESERTA 16/04/1974 SAKTI
198 0000000480429 1107151709860001 390036933 198609172006041003 MUHAJIR PESERTA 17/09/1986 PEUKAN BARO
199 0001843345045 1106146009910001 390036933 198609172006041003 HUSNAWATI ISTRI 20/09/1991 PEUKAN BARO
200 0002044572603 1107155206150002 390036933 198609172006041003 SAIVA UL KHAIRA ANAK 12/06/2015 PEUKAN BARO
201 0000000480464 1107163112700035 080122216 197012311998031005 MUHAMMAD HUSIN PESERTA 31/12/1970 PIDIE
202 0000165308095 1107165008780004 080122216 197012311998031005 FAUZIAH ISTRI 10/08/1977 PIDIE
203 0000165308106 1107164602010001 080122216 197012311998031005 FARAH ATHIFAH ANAK 06/02/2001 PIDIE

Page 6 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
204 0000165308117 1107160301050002 080122216 197012311998031005 ZAINUL RIZKI AMANDA ANAK 03/01/2005 PIDIE
205 0001869392158 1107166809080001 080122216 197012311998031005 AYYATUN SYIFA ANAK 28/09/2008 PIDIE
206 0000000480475 1107151111650001 080115443 196511111994031004 MUHAMMAD JAMIL PESERTA 11/11/1965 PEUKAN BARO
207 0000000480486 1107155001780002 080115443 196511111994031004 ITA SAFRINA ISTRI 10/01/1978 PEUKAN BARO
208 0002202631468 1107151312040004 080115443 196511111994031004 TAUFIK EFENDI ANAK 13/12/2004 PEUKAN BARO
209 0002202631301 1107155810890001 080115443 196511111994031004 MAUIDATUN NISA ANAK 18/10/1999 PEUKAN BARO
210 0000000480598 1107141106610001 080083455 196106111987031005 MUJNI PESERTA 11/06/1961 PADANG TIJI
211 0002242559799 1107141310000002 080083455 196106111987031005 OSLAM AHMADIA ANAK 13/10/2000 PADANG TIJI
212 0000000480622 1107173112670010 390023426 196712312003121018 MUSLIM PESERTA 31/12/1967 KLINIK MUTIARA
213 0000163338513 1107175109860001 390023426 196712312003121018 NURRAHMAH ISTRI 11/09/1986 SAKTI
214 0000976090127 1107171504120001 390023426 196712312003121018 MUHAMMAD ABRAR ANAK 15/04/2012 SAKTI
215 0000163338579 1107174304090001 390023426 196712312003121018 DZAKIYYAH ANAK 03/04/2009 SAKTI
216 0000000480633 1107227112740011 390038302 197412312006042005 NAZARIAH PESERTA 31/12/1974 TITEU
217 0001080474085 1107310107750001 390038302 197412312006042005 HASANUDDIN SUAMI 01/07/1975 TITEU
218 0000976807348 1107312008120001 390038302 197412312006042005 AHMAD FAEYZA ANAK 20/08/2012 TITEU
219 0000000480723 1107150206690001 080114265 196906021993031003 SAID TARMIDI AMIR PESERTA 02/06/1969 PEUKAN BARO
220 0000000480734 1107155503730002 080114265 196906021993031003 SYARIFAH MIFTAHUL JANNAH ISTRI 15/03/1973 PEUKAN BARO
221 0000000480745 1107155402970001 080114265 196906021993031003 SYARIFAH MAIZATUL AQMAL ANAK 14/02/1997 JEULINGKE
222 0001115512784 1107151909030001 080114265 196906021993031003 SAYED FAIDHIL AKBAR ANAK 19/09/2003 PEUKAN BARO
223 0000000480756 1107154611990002 080114265 196906021993031003 SYARIFAH NAZIRA ULFA ANAK 06/11/1999 PEUKAN BARO
224 0000000480802 1107094101610001 080047899 196101011981032002 SRI MULYANI PESERTA 01/01/1961 KOTA SIGLI
225 0002146990948 1107090603560001 080047899 196101011981032002 UMRAN HS SUAMI 06/03/1956 KOTA SIGLI
226 0001114892133 1107095604000001 080047899 196101011981032002 RAUDHATUN NAFIS ANAK 16/04/2000 KOTA SIGLI
227 0000000480813 1107140612640001 080089187 196412061987101001 SUARDI PESERTA 06/12/1964 KLINIK MUTIARA
228 0000166011074 1107144711790002 080089187 196412061987101001 MULYANI ISTRI 07/11/1979 KLINIK MUTIARA
229 0000166011298 1107140301020005 080089187 196412061987101001 DANIEL LUTHFI ANAK 03/01/2002 KLINIK MUTIARA
230 0000000480824 1107161407600001 390039766 196007142006041003 SULAIMAN PESERTA 14/07/1960 KLINIK MUTIARA
231 0000000480914 1107063112630018 080094263 196312311988031051 SYAMSUL BAHRI PESERTA 31/12/1963 GEULUMPANG TIGA
232 0001969593175 1107062503960002 080094263 196312311988031051 ADLI ANAK 25/03/1996 GEULUMPANG TIGA
233 0001969595932 1107061902090001 080094263 196312311988031051 MUHAMMAD ZAKI MAULANA ANAK 19/02/2009 GEULUMPANG TIGA
234 0001969594907 1107060605010002 080094263 196312311988031051 ALWI ANAK 06/05/2001 GEULUMPANG TIGA
235 0000000480958 1106140205630001 080089457 196305021987111001 TARMIZI PESERTA 02/05/1963 LEMBAH SEULAWAH (SAREE)
236 0000000480969 1106144505680002 080089457 196305021987111001 WARSIH ISTRI 05/05/1968 LEMBAH SEULAWAH (SAREE)
237 0002906535892 1106145511090001 080089457 196305021987111001 DAURIA EDBA ANAK 15/11/2009 LEMBAH SEULAWAH (SAREE)
238 0000000480993 1107162405740002 390039203 197405242006041001 T BAHARUDDIN PESERTA 24/05/1974 PIDIE
239 0000000481004 1107166107780003 390039203 197405242006041001 CUT NASRI ISTRI 21/07/1978 PIDIE
240 0000000481015 1107165203020006 390039203 197405242006041001 CUT NURLIZA FAZIRAH ANAK 12/03/2002 PIDIE
241 0002206765023 1107165911100002 390039203 197405242006041001 CUT NURUL AMALIA ANAK 19/11/2010 PIDIE
242 0000000481026 1107161506060001 390039203 197405242006041001 T. SYAHRIAL ANAK 15/06/2006 PIDIE
243 0000000481037 1106142011610001 080074230 196111201986031005 T. ZULKIIFLI PESERTA 20/11/1961 LEMBAH SEULAWAH (SAREE)
244 0000000481206 1107062309660001 080088244 196609231987101001 ZULFATAH PESERTA 23/09/1966 TEUPIN RAYA
245 0000000481228 1107090702610001 080119687 196102071995031001 ZULKIFLI PESERTA 07/02/1961 KOTA SIGLI
246 0002045158312 1107096908990001 080119687 196102071995031001 ZURRATUN NAJIHAH AZMI ANAK 29/08/1999 KOTA SIGLI
247 0000000481239 1107163012610005 080058501 196112301983021002 ZULKIFLI PESERTA 30/12/1961 KOTA SIGLI
248 0000000481252 1107165004730006 080058501 196112301983021002 SURIANA ISTRI 10/04/1973 KOTA SIGLI
249 0001272629351 1107162210020001 080058501 196112301983021002 AULIA REVIZA ANAK 22/10/2002 KOTA SIGLI
250 0000000481296 1107165307000003 080058501 196112301983021002 ZULLYANA FARICHA ANAK 13/07/2000 KOTA SIGLI
251 0000000481331 1118063112620013 080076530 196212311986031097 ABUBAKAR PESERTA 31/12/1962 BANDAR BARU
252 0002049249925 1107014107660139 080076530 196212311986031097 RITANUR ISTRI 01/07/1966 BANDAR BARU
253 0002049253683 1107017010050001 080076530 196212311986031097 DEDEK OKTAVIA ARISTA ANAK 30/10/2005 BANDAR BARU
254 0001110774587 1107011601020001 080076530 196212311986031097 ANDI NOVA ARIZAL ANAK 16/01/2002 BANDAR BARU
255 0000000481419 1107073112600018 080091205 196012311987121002 HELMI PESERTA 31/12/1960 INDRA JAYA

Page 7 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
256 0001114628038 1107076211030001 080091205 196012311987121002 RAHADATUL AISY ASSYIFA ANAK 22/11/2003 INDRA JAYA
257 0000000481522 1107164105750007 390016800 197505012001122006 NURHAYATI PESERTA 01/05/1975 PIDIE
258 0001092982904 1107160107000412 390016800 197505012001122006 MUHAMMAD SIDDIQ ANAK 01/07/2000 PIDIE
259 0000000485627 1107010108760001 X09110551 197608012009031002 JAFARUDDIN SP PESERTA 01/08/1976 BANDAR BARU
260 0000000512504 1107070406690001 196906042014061001 SAMSUL BAHRI PESERTA 04/06/1969 INDRA JAYA
261 0000000563635 1107175204690003 390058035 196904122007012001 AZIZAH PESERTA 12/04/1969 SAKTI
262 0002911917587 1171030102600001 390058035 196904122007012001 ASNAWI SUAMI 01/02/1960 SAKTI
263 0000000566381 1107144512780001 390053249 197812052007012022 DEWI KUSMALASARI PESERTA 05/12/1978 PADANG TIJI
264 0001875247345 1107140602090001 390053249 197812052007012022 ASLAFA SALVAN ANAK 06/02/2009 PADANG TIJI
265 0000172867937 1107142804060001 390053249 197812052007012022 ENDI NERDIYAN ANAK 28/04/2006 PADANG TIJI
266 0000000566919 1107163112660043 390053246 196612312007011052 EFFENDI PESERTA 31/12/1966 PIDIE
267 0001894787875 1107164210700004 390053246 196612312007011052 ZAINABON ISTRI 02/10/1970 PIDIE
268 0001894788933 1107165912020002 390053246 196612312007011052 ZELFI MAGHFIRAH ANAK 19/12/2002 PIDIE
269 0000000567549 1107124909740001 390039195 197409092006042004 ERDAWATI PESERTA 09/09/1974 LAMPASEH KOTA
270 0000000567562 1107126211060001 390039195 197409092006042004 NAILA ASY SYIFA BAIDILLAH ANAK 22/11/2006 LAMPASEH KOTA
271 0000000568157 1107245804720001 390026935 197204182005042001 ERNIDA PESERTA 18/04/1972 MUTIARA TIMUR
272 0000167380986 1107242412000001 390026935 197204182005042001 TEUKU MUHAMMAD IRHAM MARDA ANAK 24/12/2000 MUTIARA TIMUR
273 0001793399567 1107244310050001 390026935 197204182005042001 CUT WILDA NABILA MARDA ANAK 03/10/2005 MUTIARA TIMUR
274 0000167407525 1107246901030003 390026935 197204182005042001 CUT ALYA ASY SYIFA MARDA ANAK 29/01/2003 MUTIARA TIMUR
275 0000000568989 1107117112680002 390045101 196812312006042041 FARIDAH PESERTA 31/12/1968 MILA
276 0002146963004 1106213112540003 390045101 196812312006042041 NYAK ANSAH SUAMI 31/12/1954 MILA
277 0000000570892 1107097003690001 390057031 196903302007012002 HASPITAH PESERTA 30/03/1969 KLINIK MUTIARA
278 0000000570903 1107093112730005 390057031 196903302007012002 AZHAR SUAMI 31/12/1973 KLINIK MUTIARA
279 0000000572016 1107130504770001 390026952 197704052005041001 IKHSAN PESERTA 05/04/1977 KOTA SIGLI
280 0002225684709 1107131802170001 390026952 197704052005041001 MUHAMMAD DZAFRI ANAK 18/02/2017 KOTA SIGLI
281 0000167905956 1107135611080001 390026952 197704052005041001 ADZKIA ZAHRA ANAK 16/11/2008 KOTA SIGLI
282 0001079333111 1107130305120002 390026952 197704052005041001 MUHAMMAD DZAKY ANAK 03/05/2012 KOTA SIGLI
283 0000000572321 1107133112680018 390052660 196812312007011044 MUHAMMAD PESERTA 31/12/1968 KLINIK BUNDA
284 0000194274472 1107137112710003 390052660 196812312007011044 AINAL MARDHIAH ISTRI 31/12/1971 KLINIK BUNDA
285 0000000572332 1107164602670002 390051652 196702062007012003 YUSRA PESERTA 06/02/1967 KLINIK MUTIARA
286 0000000572512 1107155503800001 390065723 198003152008012001 IRMA YUSNI PESERTA 15/03/1980 PEUKAN BARO
287 0000000572927 1107062306720001 390027710 197206232005041001 ISKANDARIAH PESERTA 23/06/1972 GEULUMPANG TIGA
288 0000166834282 1107065701830001 390027710 197206232005041001 NURUL MAULIDA ISTRI 17/01/1983 GEULUMPANG TIGA
289 0000166834484 1107061808060001 390027710 197206232005041001 HARITS MUNADHIL ANAK 18/08/2006 GEULUMPANG TIGA
290 0001882779377 1107061204110001 390027710 197206232005041001 AZZAHIDI ALGIFARI ANAK 12/04/2011 GEULUMPANG TIGA
291 0000000572973 1107060802680001 390042395 196802082006041004 ISMAIL PESERTA 08/02/1968 BATEE
292 0000000573254 1107160905680002 390060244 196805092007011030 JAFARUDDIN PESERTA 09/05/1968 KOTA SIGLI
293 0000168209706 1107165309700002 390060244 196805092007011030 TI BADRI ISTRI 31/12/1972 KOTA SIGLI
294 0000168209785 1107162906030006 390060244 196805092007011030 MUAMMAR RIZKI ANAK 29/06/2003 KOTA SIGLI
295 0001112317716 1107160611070003 390060244 196805092007011030 MAHLIL AKBAR ANAK 06/11/2007 PIDIE
296 0000168209752 1107160401000004 390060244 196805092007011030 UMAR KHADAFI ANAK 04/01/2000 KOTA SIGLI
297 0000000573884 1107090707770001 390066612 197707072008011002 JULIADI PESERTA 07/07/1977 KLINIK MUTIARA
298 0000000573895 1107095702840004 390066612 197707072008011002 SANIAH ISTRI 17/02/1984 KOTA SIGLI
299 0002297468676 1107091610170001 390066612 197707072008011002 RAHANDIKA ALFARIQ ANAK 16/10/2017 KOTA SIGLI
300 0001079295625 1107094504120001 390066612 197707072008011002 PUTRI RAIHANAH ANAK 05/04/2012 KOTA SIGLI
301 0000000573906 1107096207050001 390066612 197707072008011002 SINTIA RAHMADANI ANAK 22/07/2005 KOTA SIGLI
302 0000000574885 1107150202750001 197502022014061002 IVAN TRI WAHYUDI PESERTA 02/02/1975 PEUKAN BARO
303 0000000576246 1112051704650001 390053071 196504172007011002 M. ADAM PESERTA 17/04/1965 KLINIK BUNDA
304 0000162526678 1107175002690004 390053071 196504172007011002 AINUN NAZAR ISTRI 10/02/1969 KLINIK BUNDA
305 0000162526691 1107176902080001 390053071 196504172007011002 NAZIRATUL AMIRA ANAK 29/02/2008 KLINIK BUNDA
306 0000000576314 1107163112620063 390045507 196212312006041044 M NASIR PESERTA 31/12/1962 PIDIE
307 0000000576325 1107165010680001 390045507 196212312006041044 NURJANNAH ISTRI 10/10/1968 PIDIE

Page 8 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
308 0000000576909 1107242909810001 198109292017061001 FAKHRIZAL PESERTA 29/09/1981 UJONG RIMBA
309 0000000578169 1107065003730003 390065732 197303102008012001 MARLINAWATI PESERTA 10/03/1973 GEULUMPANG TIGA
310 0000201049615 1107061503020001 390065732 197303102008012001 MUHARRAM ANAK 15/03/2002 GEULUMPANG TIGA
311 0000000579587 1107152202840001 390072096 198402222008011006 MOEKHLIES SATA PESERTA 22/02/1984 PEUKAN BARO
312 0001884864352 1107075111930002 390072096 198402222008011006 AYU MAULIDAR ISTRI 11/11/1993 PEUKAN BARO
313 0002262604138 1107156611160001 390072096 198402222008011006 NOYA QANITA ANAK 26/11/2016 PEUKAN BARO
314 0001880547614 1107156811130001 390072096 198402222008011006 KHAYLA AULYA ANAK 28/11/2013 PEUKAN BARO
315 0000000579734 1107243112670016 390045496 196712312006041055 MUHAMMAD PESERTA 31/12/1967 MUTIARA TIMUR
316 0000000579813 1107244809740002 390045496 196712312006041055 CUT MAHDIANA ISTRI 08/09/1974 MUTIARA TIMUR
317 0000000579846 1107240810010004 390045496 196712312006041055 FAZIL MAULANA ANAK 08/10/2001 MUTIARA TIMUR
318 0001115219801 1107245204070001 390045496 196712312006041055 RAISYA MAISURA ANAK 12/04/2007 UJONG RIMBA
319 0000000580285 1107163112720034 390059449 197212312007011287 MUHAMMAD NASIR PESERTA 31/12/1972 BATEE
320 0001479674812 1107036006940003 390059449 197212312007011287 RUSMINI ISTRI 20/06/1994 BATEE
321 0001882456828 1107034802150001 390059449 197212312007011287 FARADISA ANAK 08/02/2015 BATEE
322 0002060726229 1107032804160002 390059449 197212312007011287 FAIZUL AKRAM ANAK 28/04/2016 BATEE
323 0000000581455 1107157112680011 390044070 196812312006042035 MURNIWATI PESERTA 31/12/1968 KLINIK MUTIARA
324 0001386449471 1107152503020001 390044070 196812312006042035 MUHAMMAD HAIKAL ANAK 25/03/2002 KLINIK MUTIARA
325 0000000581782 1107240110710001 390045471 197110012006041010 MUSLIZAR EFFENDI PESERTA 01/10/1971 MUTIARA TIMUR
326 0000000582322 1107164805680001 390051611 196805082007012007 NANA MUTIA PESERTA 08/05/1968 KLINIK MUTIARA
327 0000000582928 1107156508820001 390065744 198208252008012001 NOERLIANI PESERTA 25/08/1982 PEUKAN BARO
328 0001114667695 1107092512810002 390065744 198208252008012001 YUDHI KURNIAWAN SUAMI 25/12/1981 PEUKAN BARO
329 0000000586765 1107164704770004 390065748 197704072008012001 NURUL SYUHADA PESERTA 07/04/1977 KLINIK MUTIARA
330 0000979817793 1107072509760001 390065748 197704072008012001 IKRAM SUAMI 25/09/1976 KLINIK MUTIARA
331 0000000587935 1107174101750003 390026954 197501012005042002 RATNA DEWI PESERTA 01/01/1975 KOTA SIGLI
332 0000194249169 1107176011090002 390026954 197501012005042002 RIFA NABILLA ANAK 20/11/2009 KOTA SIGLI
333 0000000588172 1107091112680001 390057000 196812112007011003 RAZALI PESERTA 11/12/1968 KLINIK MUTIARA
334 0000167235671 1107096005850002 390057000 196812112007011003 MARHUNI ISTRI 20/05/1985 KLINIK MUTIARA
335 0000167235715 1107090712060001 390057000 196812112007011003 M. FAUZAN ANAK 07/12/2006 KLINIK MUTIARA
336 0000197228902 1107096009100001 390057000 196812112007011003 AFRAH NABILA ANAK 20/09/2010 KOTA SIGLI
337 0000000588194 1107301007700001 390045331 197007102006041004 RAZALI PESERTA 10/07/1970 GLUMPANG BARO
338 0000000588205 1107304607740003 390045331 197007102006041004 YULIAWATI ISTRI 06/07/1974 GLUMPANG BARO
339 0001115239544 1107306811000001 390045331 197007102006041004 FITRI MULIA RAMADHANA ANAK 28/11/2000 GLUMPANG BARO
340 0000000588622 1107094109740001 390051654 197409012007012001 RISNAWATI PESERTA 01/09/1974 KLINIK MUTIARA
341 0000000589634 1107177112700033 390051645 197012312007012028 ROSMAWATI PESERTA 31/12/1970 SAKTI
342 0002236700845 1107070107740161 390051645 197012312007012028 AZHAR SUAMI 01/07/1973 SAKTI
343 0000000590231 1107154707710001 390065751 197107072008012001 RUHAIDA PESERTA 07/07/1971 PEUKAN BARO
344 0000000591423 1107153008680001 080113187 196808301993031006 SAIFA MARWANDA PESERTA 30/08/1968 MUTIARA TIMUR
345 0002080073957 1107154808800002 080113187 196808301993031006 MURNIATI ISTRI 08/08/1980 MUTIARA TIMUR
346 0002080074069 1107155703080001 080113187 196808301993031006 HAYATUN NUFUS ANAK 17/03/2008 MUTIARA TIMUR
347 0000000591939 1107251010720001 390065749 197210102008011001 SAMSUL BAHRI PESERTA 10/10/1972 GRONG-GRONG
348 0000198249478 1107254207820001 390065749 197210102008011001 RUHAYATI ISTRI 02/07/1982 GRONG-GRONG
349 0000198941422 1107256010090002 390065749 197210102008011001 NADIRATUL ISNA ANAK 20/10/2009 GRONG-GRONG
350 0000198249557 1107251011050001 390065749 197210102008011001 ADQIA RIDQI ANAK 10/11/2005 GRONG-GRONG
351 0001479653324 1107252005140001 390065749 197210102008011001 M.NURIL AUFAR ANAK 20/05/2014 GRONG-GRONG
352 0000000594279 1107151605800001 390057083 198005162007011001 SYAHRIZAL, S.ST PESERTA 16/05/1980 KOTA SIGLI
353 0000168211506 1107154304820002 390057083 198005162007011001 ELIS VIANA ISTRI 03/04/1982 KOTA SIGLI
354 0000206625723 1107152007110001 390057083 198005162007011001 MUHIBBURRAHMAN ANAK 20/07/2011 KOTA SIGLI
355 0000000595168 1107093112640005 390051641 196412312007011046 T HANAFIAH PESERTA 31/12/1964 KLINIK MUTIARA
356 0000000596114 1107151102670001 390052627 196702112007011002 USMAN PESERTA 11/02/1967 GLUMPANG BARO
357 0000000596351 1107246603700001 390052633 197003262007012003 WARDANI PESERTA 26/03/1970 UJONG RIMBA
358 0000000596979 1107092109760001 390057067 197609212007011003 YUDI RACHMAT PESERTA 21/09/1976 KOTA SIGLI
359 0000000598307 1107092012710001 390058062 197112202007011003 YUSRI A. PATRA PESERTA 20/12/1971 KLINIK MUTIARA

Page 9 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
360 0000000599016 1107241111790001 390057032 197911112007011001 ZUFRI PESERTA 11/11/1979 MUTIARA TIMUR
361 0000000599027 1107244303850001 390057032 197911112007011001 DEWI RATNA ISTRI 03/03/1985 MUTIARA TIMUR
362 0000209780166 1107242601120001 390057032 197911112007011001 RAKHA ARRAYYAN ANAK 26/01/2012 MUTIARA TIMUR
363 0002424465821 1107243012170001 390057032 197911112007011001 MUHAMMAD FARAS ANAK 30/12/2017 MUTIARA TIMUR
364 0000000599038 1107242610080001 390057032 197911112007011001 FAIRUZ NAFIS ANAK 26/10/2008 MUTIARA TIMUR
365 0000000599106 1107072605760001 390027765 197605262005041001 ZULFAHMI PESERTA 26/05/1976 INDRA JAYA
366 0000204064176 1107076606850001 390027765 197605262005041001 FERA DAYANTI ISTRI 26/06/1985 INDRA JAYA
367 0002901125654 1107076308190002 390027765 197605262005041001 RIZKIYATUSYAKIRA ANAK 23/08/2019 INDRA JAYA
368 0001085791893 1107070908130001 390027765 197605262005041001 MUHAMMAD ULIL ABSAR ANAK 09/08/2013 INDRA JAYA
369 0000195985135 1107076708100001 390027765 197605262005041001 SYAHEERATUL IFANA ANAK 27/08/2010 INDRA JAYA
370 0000000599117 1107141012770002 390036872 197712102006041006 ZULFATAN PESERTA 10/12/1977 KLINIK MUTIARA
371 0001112278544 1107144504820003 390036872 197712102006041006 DIFTA APRIANI ISTRI 05/04/1982 PADANG TIJI
372 0001112278645 1107145807100002 390036872 197712102006041006 NURUL YASINA ANAK 18/07/2010 PADANG TIJI
373 0002893271354 1107142303060001 390036872 197712102006041006 MUHAMMAD SARHINDI AL SHARUQI ANAK 23/03/2006 PADANG TIJI
374 0002893271681 1107145602080001 390036872 197712102006041006 SITI IZZATI DZILFATHANAH ANAK 16/02/2008 PADANG TIJI
375 0000000599343 1107300910710001 390065747 197110092008011001 ZULKARNAINI PESERTA 09/10/1971 GLUMPANG BARO
376 0000208373253 1107304102810002 390065747 197110092008011001 ERVINA ISTRI 01/02/1981 GLUMPANG BARO
377 0000208373286 1107304902060002 390065747 197110092008011001 YAYANG SALSABILA ANAK 09/02/2006 GLUMPANG BARO
378 0001311140103 1107300603120001 390065747 197110092008011001 MUHAMMAD AL HAFID ANAK 06/03/2012 GLUMPANG BARO
379 0001311155932 1107305108130001 390065747 197110092008011001 ZALFA NAQIYYA ANAK 11/08/2013 GLUMPANG BARO
380 0000000735941 1107153112660004 196612312014061057 ZULKIFLI PESERTA 31/12/1966 KEUMALA
381 0002899268998 1107154201760003 196612312014061057 ANITA AGUSTINA ISTRI 02/01/1976 KEUMALA
382 0002033041994 1107155302010001 196612312014061057 SAPHIRA ANAK 13/02/2001 PEUKAN BARO
383 0000000784383 1107166406650002 080091891 196506241988012002 MUSRIANI PESERTA 24/06/1965 KLINIK MUTIARA
384 0000000787915 1107197112690016 140256088 196912311990122001 KHAIRIAH PESERTA 31/12/1969 TANGSE
385 0002146879484 1271013110730001 140256088 196912311990122001 ZAMRONI YUSUF SUAMI 31/10/1973 TANGSE
386 0000000789131 1107307112660008 080126846 196612311999032010 NURAINI PESERTA 31/12/1966 KLINIK BUNDA
387 0000000789164 1107305509020001 080126846 196612311999032010 FATHIYA NABILA ANAK 15/09/2002 KLINIK BUNDA
388 0000000789153 1107304201000001 080126846 196612311999032010 DARA ULFAH ANAK 02/01/2000 KLINIK BUNDA
389 0000000789175 1107164704640002 390010964 196404071987032014 RUSNAH PESERTA 07/04/1964 PIDIE
390 0000000845583 1106120103830005 X09188394 198303012009041002 HERIZAL FAKHRI PESERTA 01/03/1983 PIDIE
391 0001289993905 1107164606890007 X09188394 198303012009041002 NURUL FAJRI ISTRI 06/06/1989 PIDIE
392 0001830677409 1107161112140001 X09188394 198303012009041002 MUHAMMAD DZAKY ALGHIFARI ANAK 11/12/2014 PIDIE
393 0002252058186 1107160204170001 X09188394 198303012009041002 MUHAMMAD ZIDAN ALGHAZI ANAK 02/04/2017 PIDIE
394 0000000845594 1107165402700001 080112776 197002141993032004 UDHIAH PESERTA 14/02/1970 KLINIK MUTIARA
395 0000000845605 1107163112620066 080112776 197002141993032004 USMAN A. BAKAR SUAMI 31/12/1962 KLINIK MUTIARA
396 0001112352884 1107166511090001 080112776 197002141993032004 MUZDALIFAH ANAK 25/11/2009 KLINIK MUTIARA
397 0001112352862 1107165812010001 080112776 197002141993032004 RAHMAH PUTRI ANAK 18/12/2001 KLINIK MUTIARA
398 0000001839835 1172010609630002 080122707 196309061998031002 ZIKRI PESERTA 06/09/1963 MILA
399 0001886118017 1107115406860001 080122707 196309061998031002 FITRIANI ISTRI 14/06/1986 MILA
400 0001886118153 1107117010140001 080122707 196309061998031002 KHAIRA ULFIZA ZIKRI ANAK 30/10/2014 MILA
401 0000003709888 1111136003920003 199203202015062001 FITRI HERAWATY PESERTA 20/03/1992 KLINIK MUTIARA
402 0000001347974 1106082908920003 199203202015062001 FIKRI ARDIAN SUAMI 29/08/1992 KLINIK MUTIARA
403 0002317918533 1111134512170001 199203202015062001 FALISHA SYAFEEQA FIKRI ANAK 05/12/2017 KLINIK MUTIARA
404 0000004485688 1109044807830002 198307082011032002 NURUL ULFAH PESERTA 08/07/1983 PEUKAN BARO
405 0000019012847 1302115005810002 X09020973 198105102009022001 DEWI FOYANI PESERTA 10/05/1981 SAKTI
406 0000038400568 1107223112670008 196712312014061039 M. HUSIN PESERTA 31/12/1967 TITEU
407 0000148718215 1107244810750002 197510082009032001 MAHNIZAR PESERTA 08/10/1975 KLINIK MUTIARA
408 0000156939085 1103113112660014 196612312007011502 A. HAMID PESERTA 31/12/1966 PANTE BIDARI
409 0000169743756 1103114107750143 196612312007011502 KHADIJAH ISTRI 01/07/1975 PANTE BIDARI
410 0001816221666 1103111102060001 196612312007011502 JAJULI ANAK 11/02/2005 PANTE BIDARI
411 0001816221341 1103114210990004 196612312007011502 ASMAUL HUSNA ANAK 02/10/1999 PANTE BIDARI

Page 10 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
412 0000156959155 1107081406770001 197706142009081001 ZULFIKAR ISMAIL PESERTA 14/06/1977 KLINIK MUTIARA
413 0000169767573 1107084808870002 197706142009081001 ROULINA BR SINAGA ISTRI 08/08/1987 KLINIK MUTIARA
414 0000170622235 1107080101080001 197706142009081001 ISMAIL RAJA BONAGA ANAK 01/01/2008 KLINIK MUTIARA
415 0000206598688 1107081010110001 197706142009081001 ISMAIL AZZAM BONAGA ANAK 10/10/2011 KOTA SIGLI
416 0001323023872 1107085404140001 197706142009081001 MALIKA MIDORI ANAK 14/04/2014 KLINIK MUTIARA
417 0000159593264 1107040105770001 390060825 197705012007011019 FAISAL PESERTA 01/05/1977 DELIMA
418 0000163656731 1107047105820001 390060825 197705012007011019 HAYATUN RAHMI ISTRI 31/05/1982 DELIMA
419 0001110699944 1107047003080001 390060825 197705012007011019 JANNATI ZUMARA ANAK 30/03/2008 DELIMA
420 0000163656966 1107041403050001 390060825 197705012007011019 SYAUKI AKBAR ANAK 14/03/2005 DELIMA
421 0000163656821 1107042105030001 390060825 197705012007011019 ALHARIS HALALIYAH ANAK 21/05/2003 DELIMA
422 0000167292437 1107010602830001 198302062017061002 BUKHARI PESERTA 06/02/1983 BANDAR BARU
423 0000173225081 1107071709740002 197409172014061005 ZULKIFLI PESERTA 17/09/1974 INDRA JAYA
424 0000194577715 1107094408790001 197908042010012007 SAMSIDAR, PESERTA 04/08/1979 KLINIK MUTIARA
425 0000194578187 1107091703810001 197908042010012007 HADIWIJAYA SUAMI 17/03/1981 KLINIK MUTIARA
426 0001328201493 1107090406130002 197908042010012007 FATHIR ATHARIZ ANAK 04/06/2013 KLINIK MUTIARA
427 0000194578446 1107096907100001 197908042010012007 FARAH ZALFADILLA ANAK 29/07/2010 KLINIK MUTIARA
428 0001080980043 1107090406130001 197908042010012007 FATHAN ATHARIZ ANAK 04/06/2013 KLINIK MUTIARA
429 0000195193855 1107086207790001 197907222010012008 HAIYATON PESERTA 22/07/1979 KLINIK CITRA BANGSA
430 0000195193866 1107082808760001 197907222010012008 BAINAL SURYA SUAMI 28/08/1976 KLINIK CITRA BANGSA
431 0000195193888 1107081501080001 197907222010012008 RAYFAL MAULANA SAIDI ANAK 15/01/2008 KLINIK CITRA BANGSA
432 0000195193923 1107082701100001 197907222010012008 HADYKA ABKARY SAIDI ANAK 27/01/2010 KLINIK CITRA BANGSA
433 0001853582016 1107081511140001 197907222010012008 GHAZY ALFARIZKY SAIDI ANAK 15/11/2014 KLINIK CITRA BANGSA
434 0000197223535 1106210108790003 197908012010031001 YUSRIL PESERTA 01/08/1979 SEULIMEUM
435 0000977522578 1106206406120001 197908012010031001 SITI JIHAN ZAFIRAH ANAK 24/06/2012 SEULIMEUM
436 0000197311342 1107191905850001 198505192010011013 SALAMUN PESERTA 19/05/1985 KOTA SIGLI
437 0000000450336 1107196810920001 198505192010011013 LISMA WARLINA HAYATI ISTRI 28/10/1992 KOTA SIGLI
438 0001886541715 1107195408140001 198505192010011013 AIRA ASTILA RANIA ANAK 14/08/2014 KOTA SIGLI
439 0002940912731 1107192311190001 198505192010011013 FAIZ AL ZYDAN ANAK 23/11/2019 KOTA SIGLI
440 0000197613393 1107073112790009 197912312010011035 IRHAS PESERTA 31/12/1979 INDRA JAYA
441 0000197613461 1107076004860002 197912312010011035 NURKAMARI ISTRI 20/04/1986 INDRA JAYA
442 0000200774856 1107071501110001 197912312010011035 AFZALUL ZIBRAN ANAK 15/01/2011 INDRA JAYA
443 0000198995679 1107165107760004 197607112009042002 CUT YUSNITA PESERTA 11/07/1976 PIDIE
444 0001480955005 1271022909740001 197607112009042002 T ISNAINI SUAMI 29/09/1974 PIDIE
445 0000199896489 1107150702870001 198702072010031001 JAMALUDDIN PESERTA 07/02/1987 KOTA SIGLI
446 0000200589434 1171025906810003 198106192015062001 ERNAWATY PESERTA 19/06/1981 KLINIK HB SENTRA MEDIKA
447 0000202991635 1107135307790001 197907132010012009 ERMANILA PESERTA 13/07/1979 KOTA SIGLI
448 0000208735986 1107084304790002 197904032010032003 NASRITA PESERTA 03/04/1979 KEUMBANG TANJONG
449 0000208736109 1101071108720001 197904032010032003 ZAPARIDUN IDRIS SUAMI 11/08/1972 KEUMBANG TANJONG
450 0000209615343 1107131205790001 197905122010011026 SAIFULLIZAN PESERTA 12/05/1979 MUTIARA BARAT
451 0000218463129 1107131601870001 198701162017061001 NAZARUDDIN PESERTA 16/01/1987 MUTIARA BARAT
452 0000219174153 1107134502880004 198701162017061001 RUHAMAH ISTRI 05/02/1988 MUTIARA BARAT
453 0002894453717 1107130105190002 198701162017061001 MUHAMMAD ZAIDAN AL- MUBARRAQ ANAK 01/05/2019 MUTIARA BARAT
454 0000218467754 1107136504880001 198804252017062003 AIZA FITRI PESERTA 25/04/1988 MUTIARA BARAT
455 0002147023449 1107181611840001 198804252017062003 IWAN SUNARYA SUAMI 16/11/1984 MUTIARA BARAT
456 0002074512025 1107137107160001 198804252017062003 ASHEEQA ZAREEN ANAK 31/07/2016 MUTIARA BARAT
457 0000218745797 1107075111830002 198311112017062001 RATNA HAFNI PESERTA 11/11/1983 INDRA JAYA
458 0002146984593 1107070107840336 198311112017062001 ARMIYA SUAMI 13/10/1983 INDRA JAYA
459 0002146984604 1107075212110002 198311112017062001 ZAKIATUL AUWARA ANAK 12/12/2011 INDRA JAYA
460 0002146984615 1107075206160002 198311112017062001 ASYOUMI KHALIFA ANAK 12/06/2016 INDRA JAYA
461 0000218765428 1107151708890005 198908172017061001 MUHAMMAD JAFARUDDIN PESERTA 17/08/1989 SAKTI
462 0000219033347 1107175211920002 198908172017061001 HANIFAH ISTRI 12/11/1992 SAKTI
463 0002624964366 1107170302180002 198908172017061001 MUHAMMAD RAFFA AZIZI ANAK 03/02/2018 SAKTI

Page 11 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
464 0002051765796 1107175901140001 198908172017061001 ASYIFA TUNNISA ANAK 19/01/2014 SAKTI
465 0000218879267 1107141611860001 198611162017061001 IRWAN PESERTA 16/11/1986 PADANG TIJI
466 0001115615981 1107144606900003 198611162017061001 MAINURA ISTRI 06/06/1990 PADANG TIJI
467 0002897066259 1107146504190002 198611162017061001 MOZA VITA ANAK 25/04/2019 PADANG TIJI
468 0002223241424 1107144712150002 198611162017061001 WINDIRA AIKA ANAK 07/12/2015 PADANG TIJI
469 0000218882068 1107044208850001 198508022017062003 DAKIATON PESERTA 02/08/1985 DELIMA
470 0000979777067 1107042505690001 198508022017062003 MUHAMMAD JAFAR SUAMI 25/05/1968 DELIMA
471 0002615430295 1107041611180001 198508022017062003 RAYYAN AT TAMIMI ANAK 16/11/2018 DELIMA
472 0000219158166 1107155206880001 198803122017062001 MUSLIANI PESERTA 12/06/1988 PEUKAN BARO
473 0000979630547 1107131205820001 198803122017062001 MUHAMMAD DEWI SUAMI 12/05/1982 PEUKAN BARO
474 0002909267032 1107151104180001 198803122017062001 AZRIL SAPUTRA ANAK 11/04/2018 PEUKAN BARO
475 0002292150508 1107156207160001 198803122017062001 KEISHA VARISHA ANAK 22/07/2016 PEUKAN BARO
476 0000979572824 1107061205870004 198705122017061002 MUHAMMAD ERWIN PESERTA 12/05/1987 TEUPIN RAYA
477 0002899169278 1107061510190001 198705122017061002 MUHAMMAD AQIEL HABIBIE ANAK 15/10/2019 TEUPIN RAYA
478 0002247132227 1107064604170001 198705122017061002 AQIELA HUMAIRA ANAK 06/04/2017 TEUPIN RAYA
479 0000979585953 1107066704840001 198404272017062002 NURLAILA PESERTA 27/04/1984 TEUPIN RAYA
480 0002090030231 1107131511800001 198404272017062002 LUKMAN SUAMI 15/11/1980 MUTIARA BARAT
481 0000979686527 1107194510840004 198410052017062001 ABRIDA YANI PESERTA 05/10/1984 TANGSE
482 0000979686516 1107190101800003 198410052017062001 AHMADI YUSUF SUAMI 01/01/1980 TANGSE
483 0000979686538 1107195907060002 198410052017062001 AZRA FADHILLA ANAK 19/07/2006 TANGSE
484 0002323724398 1107192407110001 198410052017062001 KAFILLA ALHAKIM ANAK 24/07/2011 TANGSE
485 0002092009498 1107191110160001 198410052017062001 AHMAD ZIKRA HUNAIYA ANAK 11/10/2016 TANGSE
486 0000979840449 1107156810870001 198710282017062002 MULIANI PESERTA 28/10/1987 PEUKAN BARO
487 0000214034297 1171040201880001 198710282017062002 TONI SAPUTRA SUAMI 02/01/1988 PEUKAN BARO
488 0000979850351 1107150408860003 198608042017061001 ZULFAHMI PESERTA 04/08/1986 PEUKAN BARO
489 0001274921897 1107154804900003 198608042017061001 NURBAYANI ISTRI 08/04/1990 PEUKAN BARO
490 0002067908411 1107157005140001 198608042017061001 ZAHRA FATUL JINAN ANAK 30/05/2014 PEUKAN BARO
491 0002067908207 1107150304130001 198608042017061001 MUHAMMAD MULTAZAM ANAK 03/04/2013 PEUKAN BARO
492 0002910727978 1107155804190001 198608042017061001 AISYAH ZAHIRA ANAK 18/04/2019 PEUKAN BARO
493 0001081628526 1107300507810001 198107052012121006 KAFRAWI PESERTA 05/07/1981 TANGSE
494 0001081628583 1107305405870002 198107052012121006 SURYANI ISTRI 14/05/1987 TANGSE
495 0002060729605 1107192105160001 198107052012121006 MUHAMMAD DANIL ANAK 21/05/2016 TANGSE
496 0001081628638 1107301004110001 198107052012121006 MUHAMMAD NAUVAL ANAK 10/04/2011 TANGSE
497 0001081628954 1107151512640001 196412152012121002 NUR HAFLI PESERTA 15/12/1964 PEUKAN BARO
498 0001081629077 1107156810800001 196412152012121002 ROSMAWATI ISTRI 28/10/1980 PEUKAN BARO
499 0001081629145 1107151106080001 196412152012121002 MUHAMMAD DARUL ABRIL ANAK 11/06/2008 PEUKAN BARO
500 0001081629101 1107155412050001 196412152012121002 TASYA NABILA ANAK 14/12/2005 PEUKAN BARO
501 0002931831009 1107155201160001 196412152012121002 SYIHARATUN NAJWA ANAK 12/01/2016 PEUKAN BARO
502 0001081629527 1107212812720001 197212282012121001 JABIR PESERTA 28/12/1972 INDRA JAYA
503 0001081629584 1107074510780002 197212282012121001 RAHMIATI ISTRI 05/10/1978 INDRA JAYA
504 0001082286268 1107160107640382 196412311998031025 SOFYAN PESERTA 31/12/1964 KOTA SIGLI
505 0001110842875 1107173112660004 196612312014061058 ZAINAL ABIDIN PESERTA 31/12/1966 SAKTI
506 0001110842886 1107174408730003 196612312014061058 ERLINA ISTRI 04/08/1973 SAKTI
507 0001110847105 1107176107710001 197107212014062002 CUT YUSNIDAR PESERTA 21/07/1971 SAKTI
508 0001110847072 1107172010730001 197107212014062002 SAFRIZAL SUAMI 20/10/1973 SAKTI
509 0001110846982 1107172804060001 197107212014062002 ZAIZAL MUSTAQIM ANAK 28/04/2006 SAKTI
510 0001110847127 1107177005030001 197107212014062002 TASYA NAZURA ANAK 30/05/2003 SAKTI
511 0001886112044 1107175302140002 197107212014062002 INAYA AZMI ATHIFA ANAK 13/02/2014 SAKTI
512 0001112883041 1107244206850001 198506022017062004 FATRIAH PESERTA 02/06/1985 UJONG RIMBA
513 0002088880378 1107243112820017 198506022017062004 SYUKRI SUAMI 31/12/1982 UJONG RIMBA
514 0002088881379 1107242209110001 198506022017062004 MUHAMMAD DAFFA ANAK 22/09/2011 UJONG RIMBA
515 0002088881559 1107242701130001 198506022017062004 RAFKA AULIA ANAK 27/01/2013 UJONG RIMBA

Page 12 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
516 0002303570338 1107246305170002 198506022017062004 MOZA ADELIA ANAK 23/05/2017 UJONG RIMBA
517 0001113081794 1107166607830003 198307262017062002 HIDAYANI PESERTA 26/07/1983 PIDIE
518 0002146831277 1107161209830003 198307262017062002 MAHYARUDDIN SUAMI 12/09/1983 PIDIE
519 0002146831288 1107160702160001 198307262017062002 ABIZAR ASH SHIDDIQY ANAK 07/02/2016 PIDIE
520 0001114235548 1107096201820001 198201222017062002 FITRI YANTI PESERTA 22/01/1982 KOTA SIGLI
521 0001114235482 1107090709730001 198201222017062002 MUNAWWAR, ST SUAMI 07/09/1973 KOTA SIGLI
522 0002044798514 1107095411150001 198201222017062002 FARISHA AMIRAH ANAK 14/11/2015 KOTA SIGLI
523 0001114235684 1107091911070001 198201222017062002 FAYYADH ALTHIF ANAK 19/11/2007 KOTA SIGLI
524 0001114235561 1107090301060001 198201222017062002 FADHAL AFIF ANAK 03/01/2006 KOTA SIGLI
525 0001114506257 1107171707810002 198107172015061001 TARMIZI PESERTA 17/07/1981 INDRA JAYA
526 0001902086717 1107074611920002 198107172015061001 RIZKA AMELIA ISTRI 06/11/1992 INDRA JAYA
527 0002225633949 1107076601170001 198107172015061001 KHANZA ARISTA ANAK 26/01/2017 INDRA JAYA
528 0002897582725 1107072109190001 198107172015061001 MUHAMMAD AL FATIH ANAK 21/09/2019 INDRA JAYA
529 0001114659606 1107075505850002 198505152017062002 AFIZAHRANI PESERTA 15/05/1985 INDRA JAYA
530 0002302721471 1107160203840001 198505152017062002 SABIRIN SUAMI 02/03/1984 INDRA JAYA
531 0002451804614 1107072601180001 198505152017062002 BAIDAWI ANAK 26/01/2018 INDRA JAYA
532 0002302722189 1107070209160001 198505152017062002 NAHRAWI ANAK 02/09/2016 INDRA JAYA
533 0002302721919 1107071109150001 198505152017062002 MARBAWI ANAK 11/09/2015 INDRA JAYA
534 0001114691409 1107092710750001 197510272014061004 NASRUAN AIDIL PESERTA 27/10/1975 KOTA SIGLI
535 0001273954599 1107095104790001 197510272014061004 RISMAWATI ISTRI 11/04/1979 KOTA SIGLI
536 0002262448361 1107090507170001 197510272014061004 FAUZAN AL ATSARI ANAK 05/07/2017 KOTA SIGLI
537 0001278681636 1107095902110001 197510272014061004 FAIZAH AL ATSARIAH ANAK 19/02/2011 KOTA SIGLI
538 0001887424964 1107096607120001 197510272014061004 AFIFAH ANAK 26/07/2012 KOTA SIGLI
539 0001114840315 1107092907850001 198507292017061001 MIRZA FIRDIANSYAH PESERTA 29/07/1985 PEUKAN BARO
540 0000218758746 1107156611910001 198507292017061001 NUR AZIZAH ISTRI 26/11/1991 PEUKAN BARO
541 0001114868812 1107060710840002 198410072017061002 MUHAMMAD RAJID PESERTA 07/10/1984 TEUPIN RAYA
542 0001114892076 1107090207890002 198907022017061001 ZULFAJRI UMRAN PESERTA 02/07/1989 KOTA SIGLI
543 0000218762561 1107146307930002 198907022017061001 MEGA WATI ISTRI 23/07/1993 PADANG TIJI
544 0002894409641 1107141312170001 198907022017061001 MUHAMMAD ALGHAZI ANAK 13/12/2017 KOTA SIGLI
545 0001115166576 1107301708880002 198808172017061002 TAUFIQ PESERTA 17/08/1988 GLUMPANG BARO
546 0001115194577 1107305404910002 198808172017061002 WAHIDAH ISTRI 14/04/1991 GLUMPANG BARO
547 0002060979142 1107301711150001 198808172017061002 MUHAMMAD KHALIF ANAK 17/11/2015 GLUMPANG BARO
548 0002925569812 1107297101200001 198808172017061002 ARIQA FATINA ANAK 31/01/2020 GLUMPANG BARO
549 0001115220183 1107184810770002 197710082014062004 ASLAMIAH PESERTA 08/10/1977 SIMPANG TIGA (PIDIE)
550 0001326566687 1107180204780002 197710082014062004 SAIFUDDIN SUAMI 02/04/1978 SIMPANG TIGA (PIDIE)
551 0001115220227 1107185407090001 197710082014062004 AZRA UFAIRAH ANAK 14/07/2009 SIMPANG TIGA (PIDIE)
552 0001115252065 1107220202830001 198501022017061002 NAZARUDDIN PESERTA 02/01/1985 GEUMPANG
553 0002763798445 1107055010880001 198501022017061002 NURLAILA ISTRI 10/10/1988 GEUMPANG
554 0002250541337 1107050709130001 198501022017061002 ABIZAR ANAK 07/09/2013 GEUMPANG
555 0001115451685 1107122410810001 198110242017061001 SHAFRAN PESERTA 24/10/1981 MUARA TIGA
556 0001115451731 1107125409870001 198110242017061001 ELIANUR ISTRI 14/09/1987 MUARA TIGA
557 0001115451775 1107122706090002 198110242017061001 SULTHAN ALAIDIN SYAH ANAK 27/06/2009 MUARA TIGA
558 0002224864293 1107120503140002 198110242017061001 RIYAD AMINI ANAK 05/03/2014 MUARA TIGA
559 0001115487753 1107302209680001 196809222014061004 BUSTAMI PESERTA 22/09/1968 GLUMPANG BARO
560 0001115487808 1107305704760001 196809222014061004 ELLY ISTRI 17/04/1976 GLUMPANG BARO
561 0001115487898 1107302809980001 196809222014061004 MUHAMMAD IKHSAN ANAK 28/09/1998 GLUMPANG BARO
562 0001115487911 1107302806010001 196809222014061004 IKHWANI ANAK 28/06/2001 LEMBAH SEULAWAH (SAREE)
563 0001115487955 1107301412040001 196809222014061004 RIDZAYI ANAK 14/12/2004 GLUMPANG BARO
564 0001283598742 1107060107660122 196607012014061002 NURDIN PESERTA 01/07/1966 GEULUMPANG TIGA
565 0001301216681 1107064107720251 196607012014061002 NURLAILI ISTRI 01/07/1972 GEULUMPANG TIGA
566 0001886858785 1107062012040001 196607012014061002 NOVAL RIZAL ANAK 20/12/2004 GEULUMPANG TIGA
567 0001326549216 1107155010870002 198710102017062002 JULI ANDALENA PESERTA 10/10/1987 PEUKAN BARO

Page 13 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
568 0001426064771 1107076805800002 198005282014062008 MISNAWATI PESERTA 28/05/1980 INDRA JAYA
569 0001426064321 1107071006670003 198005282014062008 ABDULLAH SYAMAUN SUAMI 10/06/1967 INDRA JAYA
570 0001426065197 1107075108090002 198005282014062008 LAYYA LATIFA ANAK 11/08/2009 INDRA JAYA
571 0001426066514 1107071811130001 198005282014062008 RAYYAN HAFIZ ANAK 18/11/2013 INDRA JAYA
572 0001436662113 1107075607790002 197907162014062004 IRMA SUSANTI PESERTA 16/07/1979 INDRA JAYA
573 0001436662091 1107070112740002 197907162014062004 ISWANDI SUAMI 01/12/1974 INDRA JAYA
574 0001436662157 1107070908030001 197907162014062004 MUHAMMAD RAFLI RYANDI ANAK 09/08/2003 INDRA JAYA
575 0001449324055 1107156001890001 198901202017062001 NURUL RAHMAH PESERTA 20/01/1989 BP AA MEDICAL
576 0001115019358 1107151007820003 198901202017062001 ISMAIL SUAMI 10/07/1982 BP AA MEDICAL
577 0001821812231 1107150402150001 198901202017062001 AKBAR ALAUDDIN ANAK 04/02/2015 BP AA MEDICAL
578 0002054245511 1107150504110001 198901202017062001 FARIS DAWLAH NASIR ANAK 05/04/2011 BP AA MEDICAL
579 0001115019527 1107152301090001 198901202017062001 MUNTAZAR AL ZAIDI ANAK 23/01/2009 BP AA MEDICAL
580 0001483220979 1107064101870002 198701012017062003 MAISURA PESERTA 01/01/1987 UJONG RIMBA
581 0001799244843 1107240408840004 198701012017062003 RAFII SUAMI 04/08/1984 UJONG RIMBA
582 0001799248162 1107242108110002 198701012017062003 FAIZ RAMADHAN ANAK 21/08/2011 UJONG RIMBA
583 0002054167795 1107246701150001 198701012017062003 ANNISA LUTHFIA ANAK 27/01/2015 UJONG RIMBA
584 0002428372168 1107240802180001 198701012017062003 BILAL ZAFRAN ANAK 08/02/2018 UJONG RIMBA
585 0001799272236 1107301601860001 198601162017061001 JAFRIZAL PESERTA 16/01/1986 BANDAR BARU
586 0001813775117 1107185712830002 198312172017062002 NOVAYANTI BR PERANGIN ANGIN PESERTA 17/12/1983 SIMPANG TIGA (PIDIE)
587 0001876320652 1107171703690001 196903172014101001 AKMAL ZUHRI PESERTA 17/03/1969 SAKTI
588 0001110837251 1107176801830001 196903172014101001 DWI MAULIDAR ISTRI 28/01/1983 SAKTI
589 0001876324026 1104176812120001 196903172014101001 RANIA AMEERA ANAK 28/12/2012 SAKTI
590 0002086872535 1107170405160001 196903172014101001 ARZAN IRHASH ANAK 04/05/2016 SAKTI
591 0001876322902 1107176910050001 196903172014101001 DIVA RAMADHANI ANAK 29/10/2005 SAKTI
592 0001884427806 1107244612650001 196512312014062026 MAULINA PESERTA 31/12/1965 MUTIARA TIMUR
593 0001873112354 1107190107650286 196512312014062026 ABDUL RAZAK SUAMI 01/07/1965 MUTIARA TIMUR
594 0001885856624 1107174104810003 198104012014062006 SRI SUSILAWATI PESERTA 01/04/1981 SAKTI
595 0001885858064 1107170103780002 198104012014062006 ZULFAHMI SUAMI 01/03/1978 SAKTI
596 0001885859335 1107176911100002 198104012014062006 AUDINI FAHIRA ANAK 29/11/2010 SAKTI
597 0002041182753 1107174511150001 198104012014062006 ARSYILA ALTHAFUNNISA ANAK 05/11/2015 SAKTI
598 0001886112909 1107177112760016 197612312014062012 NAZARIAH PESERTA 31/12/1976 SAKTI
599 0001110731321 1107173112690040 197612312014062012 ANWAR SUAMI 31/12/1969 SAKTI
600 0001110731365 1107176001050002 197612312014062012 NAZIRATUL HUSNA ANAK 20/01/2005 SAKTI
601 0001886114542 1107155203640001 196403122014062002 JAMILAH PESERTA 12/03/1964 PEUKAN BARO
602 0001886116059 1107075502780001 197802152014062007 RATNA PESERTA 15/02/1978 INDRA JAYA
603 0001886116083 1107070806730001 197802152014062007 JUNAIDAR SUAMI 08/06/1973 INDRA JAYA
604 0001886116105 1107072801020003 197802152014062007 NAUFAL ZHARIF ANAK 28/01/2002 INDRA JAYA
605 0001438902562 1107070909120001 197802152014062007 YAFIQ ABRAR ANAK 09/09/2012 INDRA JAYA
606 0001886116149 1107075108070001 197802152014062007 PUTROE AFIFAH AFRA ANAK 11/08/2007 INDRA JAYA
607 0001886556609 1107075307810001 198107132014062008 NURAZIZAH PESERTA 13/07/1981 INDRA JAYA
608 0002432063755 1107076002180001 198107132014062008 ANNISA LATHIFAH ZALFA ANAK 20/02/2018 INDRA JAYA
609 0002903818037 1107073110190001 198107132014062008 LUTHFI AZKA RIZQULLAH ANAK 31/10/2019 INDRA JAYA
610 0001886610969 1107082009690001 196909202014061002 SYUKRI PESERTA 20/09/1969 KEUMBANG TANJONG
611 0001886738692 1107074706780002 197706072014062003 ANANI PESERTA 07/06/1977 INDRA JAYA
612 0001886740593 1107070508140001 197706072014062003 KATHIBUL UMAM ANAK 05/08/2014 INDRA JAYA
613 0001115392094 1107071804100001 197706072014062003 REJA SAIF FADHAIL ANAK 18/04/2010 INDRA JAYA
614 0001887410013 1107095508690001 196908152014062006 DETTI AZWANI PESERTA 15/08/1969 KOTA SIGLI
615 0001887410248 1107091006690002 196908152014062006 IRWANTO SUAMI 10/06/1969 KOTA SIGLI
616 0001887410766 1107090708990001 196908152014062006 MUHAMMAD AQIL SIRAJ ANAK 07/08/1999 KOTA SIGLI
617 0001896706067 1171011905840001 198405192017061001 MISWARUL FAJRI PESERTA 19/05/1984 BAITURRAHMAN
618 0002324957444 3604044905870003 198405192017061001 MUTIA ISTRI 09/05/1987 BAITURRAHMAN
619 0002040104529 1107084808890001 198908082017062001 MURHANIM PESERTA 08/08/1989 MUTIARA TIMUR

Page 14 of 15
 NOMOR INDUK
NOMOR KARTU HUB. KETERANGAN VERIFIKASI (DI ISI OLEH SATKER DENGAN
NO. JKN-KIS KEPENDUDUKAN NIPLAMA NIPBARU NAMA KELUARGA TGL. LAHIR Nama Faskes Tingkat I PILIH SALAH SATU)
(NIK)
620 0002045495676 1107080209830001 198908082017062001 GUNAWAN SUAMI 02/09/1983 MUTIARA TIMUR
621 0002045495799 1107244912130001 198908082017062001 NABILA PUTRI SHAFWAH ANAK 09/12/2013 MUTIARA TIMUR
622 0002471637262 1107241002160002 198908082017062001 MUHAMMAD AL-HAFIZH ANAK 10/02/2016 MUTIARA TIMUR
623 0002045495777 1107085404090002 198908082017062001 MAULIZA NURUL HARFI ANAK 14/04/2009 MUTIARA TIMUR
624 0002053962685 1107184108890005 198908012017062002 ASMANIAR PESERTA 01/08/1989 KLINIK CITRA BANGSA
625 0000219127048 1107180606780002 198908012017062002 M. AMIN BIN ABDURRAHMAN SUAMI 06/06/1978 KLINIK CITRA BANGSA
626 0000219127724 1107182111090001 198908012017062002 AIDIL FUDHARI ANAK 21/11/2009 KLINIK CITRA BANGSA
627 0001908532574 1107131411130002 198908012017062002 MUHAMMAD FAIZUL HAQIQI ANAK 14/11/2013 KLINIK CITRA BANGSA
628 0002086558571 1116024903900001 199003092017062001 NURLISA PESERTA 09/03/1990 TEUPIN RAYA
629 0002146777312 1107145211880003 198811122017062002 RAHMA WATI PESERTA 12/11/1988 PADANG TIJI
630 0002146777301 1107140612830001 198811122017062002 MUHAMMAD RIANSYAH SUAMI 06/12/1983 PADANG TIJI
631 0002146777323 1107142508160001 198811122017062002 MUHAMMAD SUBQI AL FARISI ANAK 25/08/2016 PADANG TIJI
632 0001908547907 1107142411110001 198811122017062002 MUHAMMAD RAISYAL ARWIA ANAK 24/11/2011 PADANG TIJI
633 0002146836611 1107170909820001 198209092017061005 MIRZA PESERTA 09/09/1982 SAKTI
634 0000219816009 1107174403890001 198209092017061005 NINA LARIKI ISTRI 04/03/1989 SAKTI
635 0002328325918 1107176804170001 198209092017061005 MIKHAELA HAFIDZA ANAK 28/04/2017 SAKTI
636 0002146836622 1107176707150001 198209092017061005 RANIA ADZKIYA ANAK 27/07/2015 SAKTI
637 0002146956715 1107061703860001 198603172017061001 MUHAMMAD NAZAR PESERTA 17/03/1986 GLUMPANG BARO
638 0001981953944 1107306906920001 198603172017061001 YUSNIAR ISTRI 29/06/1992 GLUMPANG BARO
639 0002146956726 1107304106110001 198603172017061001 RISKIA HUMMAIRA ANAK 01/06/2011 GLUMPANG BARO
640 0002255622748 1107184108890002 198908012017062003 ASMANIDAR PESERTA 01/08/1989 SIMPANG TIGA (PIDIE)
641 0001115502759 1107300411780001 198908012017062003 BUSTAMIRUDDIN SUAMI 04/11/1978 SIMPANG TIGA (PIDIE)
642 0002255622906 1107186008140001 198908012017062003 WIDIATUL AHYA ANAK 20/08/2014 SIMPANG TIGA (PIDIE)
643 0002274084832 1107061506710004 197106152014061001 SAIFUNI PESERTA 15/06/1971 GEULUMPANG TIGA
644 0002274136402 1107180905680001 196805092014061003 YUSRI PESERTA 09/05/1968 KLINIK MUTIARA
645 0002317794658 1107174605820003 198205062017062004 MARIYAH PESERTA 06/05/1982 MILA
646 0002146734235 1107112512750002 198205062017062004 YUSRA SUAMI 23/03/1975 MILA
647 0002146734246 1107171102140002 198205062017062004 MUHAMMAD NIZAM ANAK 11/02/2014 MILA
648 0002776400019 1107112402160001 198205062017062004 BAYI NYONYA MARIYAH ANAK 11/07/2019 MILA
649 0001893810093 1107170810150001 198205062017062004 FARID ASHRAF ANAK 08/10/2015 MILA
650 0002323055441 1107010703870001 198703072017061001 BUSTANIL PESERTA 07/03/1987 BANDAR BARU
651 0001830782957 1108155109890001 198703072017061001 SAFRIANI ISTRI 11/09/1989 SAWANG
652 0002489521059 1118064702180001 198703072017061001 DARA RIZQIA FAIZA ANAK 07/02/2018 BANDAR BARU
653 0002483623798 1107173009840001 198409302017061002 TARMIZI SULAIMAN PESERTA 30/09/1984 SAKTI
654 0002483624158 1106124503910001 198409302017061002 FAUZIAH ISTRI 05/03/1991 SAKTI
655 0002778173256 1107171807190001 198409302017061002 KANA ZAYYAN ALGIBRAN ANAK 18/07/2019 SAKTI

Banda Aceh, .... Juli 2020

Pimpinan Satuan Kerja
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= =
Pembina
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