RT. 002, RW.

006
Dusun Sawur Kembang, Desa Kenanten, Kec. Puri, Kab. Mojokerto

SURAT PENGANTAR / KETERANGAN

No.............................................................

Yang bertanda tangan di bawah ini, menerangkan :

Nama lengkap : .............................................................................................
Tempat, tanggal lahir : .............................................................................................
Agama : .............................................................................................
Status : .............................................................................................
Kewarganegaraan : .............................................................................................
Pekerjaan : .............................................................................................
Alamat : .............................................................................................
Nomor KK / KTP : .............................................................................................
Keperluan : .............................................................................................
Keterangan lain : .............................................................................................

Demikian agar mendapat bantuan seperlunya. Atas perhatian dan kerjasamanya kami
sampaikan terimakasih.

Mojokerto, 20

Ketua RT 002, Yang bersangkutan,

( ) ( )

Mengetahui,
Kepala Dusun Ketua RW 006,

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