Telah Terima dari,

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

Alamat : ..................................................................................................................... .......................................................
Keterangan : ..................................................................................................................... .......................................................
Berupa : ..................................................................................................................... .......................................................
..................................................................................................................... .......................................................
Untuk Keperluan : ..................................................................................................................... .......................................................

Yang Menyerahkan, Penerima,

( ) ( )

Lembaga Amil Zakat, Infaq, dan Shodaqah Muhammadiyah (LAZNAS SK Kemenag RI No. 730 Tahun 2016)
Kantor Layanan Lazismu GKB
Alamat : Jl. Demak No. 7 Yosowilangon 61151 Gresik, telp. 031 3930208
E-mail: lazismugkb07@gmail.com