Nomor : ....................................
Nama : ...............................................................................................................................
NIP : ...............................................................................................................................
Pangkat/Golongan : ...............................................................................................................................
Jabatan : Kepala ................................................................................................................
Selaku Penanggung Jawab BOS
Alamat : ...............................................................................................................................
Demikian pernyataan ini kami buat dengan sebenarnya untuk dipergunakan sebagaimana mestinya.
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NIP. .............................................