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SURAT PERNYATAAN

Yang bertanda tangan di bawah ini :


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.

……….. , ……….2020
Yang menyatakan,

Materai 6.000

……………………..

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