MASJID/MUSHOLLA : .........................................................................
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KECAMATAN : .........................................................................
PRIODE 2021-2024
Pelindung : .............................................................
Ketua : .............................................................
Wakil Ketua : .............................................................
Sekretaris : .............................................................
Wakil Sekretaris : .............................................................
Bendahara : .............................................................
Wakil Sekretaris : .............................................................
Ditetapkan di : ...................................................
Pada Tanggal : ...................................................
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Ketua, Sekretaris,
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Keterangan :
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situasi dan kondisi di daerah masing-masing.