SURAT PERNYATAAN TANGGUNG JAWAB MUTLAK (SPTJM)

KEBENARAN DATA

Saya yang bertanda tangan dibawah ini :

Nama : ..................................................................................................................................
NIK : ..................................................................................................................................
Tempat : ..................................................................................................................................
Tanggal Lahir : ..................................................................................................................................
Pekerjaan : ..................................................................................................................................
Alamat : ..................................................................................................................................
..................................................................................................................................

Menyatakan bahwa akta ................................................................................................ Nomor

.................................................................................................................................................atas nama
.................................................................................................... anak laki-laki / perempuan suami istri
................................................................. dan ............................................................ yang dilahirkan di
............................... pada tanggal ...................................................................................... diterbitkan di
.............................................. pada tanggal ............................................................... oleh kepala kantor
Catatan Sipil ................................................................................................... dan ditanda tangani oleh
............................................................., NIP ....................................................................... yang kutipan
ASLINYA TELAH HILANG berdasarkan surat tanda penerima laporan kehilangan surat / barang yang di
keluarkan oleh Resort Metropolitan ........................................................................................................
Nomor ....................................... tanggal ................................................................

Surat Pernyataan ini saya buat untuk melengkapi persyaratan administrasi .............................
............................................................................................

Demikian agar yang berkepentingan menjadi maklum.

Jakarta, ....................................
Yang Menyatakan,

Materai cukup

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