SURAT KETERANGAN IZIN

Yang bertanda tangan dibawah ini :

Nama : ..........................................................................................................

NIK : ..........................................................................................................

Alamat : ..........................................................................................................
..........................................................................................................

Dengan ini mengizinkan Anak/Istri/Suami :

Nama : ..........................................................................................................

NIK : ..........................................................................................................

Alamat : ..........................................................................................................
..........................................................................................................

Untuk pengurusan Pembuatan / Penerbitan SKPWNI (Surat Keterangan

Pindah WNI ) / SKDWNI (Surat Keterangan Datang WNI). :

Untuk pindah alamat Ke.........................................................................................................

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

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

Dengan alasan pindah...........................................................................................................

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

Demikian, terima kasih.

Ngamprah, ......................................

Yang mengizinkan

Catatan :

Lampirkan Foto Copy KTP

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