Yang bertanda tangan di bawah ini Kepala Sekolah Dasar Negeri Dukuh 1 Kecamatan Ngadiluwih Kabupaten
Kediri Provinsi Jawa Timur, menerangkan bahwa :
mengalami kerusakan :
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seharusnya .................................................................................................................................................................
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Pas foto terbaru Kepala Sekolah
3 x 4 cm
cap tiga jari
tengah tangan Materai
kiri
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NIP.
Mengetahui,
Kepala Dinas Pendidikan Pemuda dan Olahraga
Kabupaten Kediri
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NIP.