I. IDENTITAS PEMOHON
Nama : ................................................................................................
Tempat/Tgl. Lahir : .................................................................................................
Jenis Kelamin : ................................................................................................
Agama : ...............................................................................................
Golongan Darah (*) : ................................................................................................
Alamat/Telepon/HP (*) : .................................................................................................
Pekerjaan : ................................................................................................
Keterangan Miskin : SKTM/JAMKESMAS/GAKIN/Terlampir
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III. Demikian permohonan ini saya buat dengan sesungguhnya untuk keperluan mendapat
bantuan hukum.
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Pemohon
(Nama Terang)