SURAT PERNYATAAN PENGHASILAN

ORANG TUA/WALI MAHASISWA

Assalamualaikum Wr. Wb.

Saya yang bertanda tangan di bawah ini:
Nama Ayah :....................................................................................................................
Tempat/Tgl. Lahir :....................................................................................................................
No. KTP : ....................................................................................................................
Alamat Rumah : ....................................................................................................................
No HP/WA : ....................................................................................................................
Nama Ibu : ....................................................................................................................
Tempat/Tgl. Lahir : ...................................................................................................................
No. KTP : ...................................................................................................................
Alamat Rumah : ...................................................................................................................
No HP/WA : ...................................................................................................................
Sebagai orang tua/wali dari mahasiswa tersebut di bawah ini:
Nama : ...................................................................................................................
Tempat/Tgl Lahir : ...................................................................................................................
Jurusan/Fakultas : ...................................................................................................................
Jalur Kelulusan : ...................................................................................................................
menyatakan bahwa saya:
1.Ayah bekerja sebagai.......................................................di.........................................................
2.Penghasilan perbulan (Ayah) : Rp..............................................................................................
(dilampirkan bukti penghasilan)
3. Ibu bekerja sebagai..........................................................di.........................................................
4. Penghasilan perbulan (Ibu) :
Rp ..................................................................................................
(dilampirkan bukti penghasilan)
5. Jumlah Penghasilan Ayah + Ibu : Rp ..........................................................................................
3.Jumlah tanggungan keluarga saat ini sebanyak................................................................orang.

Demikian surat pernyataan ini saya buat dengan penuh kesadaran dan tanpa ada paksaan dari
pihak manapun.

Wassalamualaikum Wr. Wb

Hormat Kami,

(Nama Ayah) (Nama Ibu)

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

Mengetahui:
Kepala Desa/Lurah

________________________
Catatan:
Mohon ditulis No HP Kades/Lurah: .....................................................