Nama : .............................................................................................. No. KK : .............................................................................................. NIK : .............................................................................................. TTL : .............................................................................................. Alamat : .............................................................................................. No. HP : .............................................................................................. Orang tua dari mahasiswa(i) : Nama : .............................................................................................. NIM : .............................................................................................. NIK : .............................................................................................. Fakultas : .............................................................................................. Program Studi : .............................................................................................. Angkatan/Semester..........................................................................................: Alamat : .............................................................................................. No. Hp. : .............................................................................................. Email : .............................................................................................. Dengan ini menyatakan bahwa saya benar – benar terdampak Covid 19 hingga menyebabkan penghasilan menurun.