Kepada : ....................................................................................................................
Perihal : ....................................................................................................................
Dari : ..................................................................................................................
Alamat : ....................................................................................................................
....................................................................................................................
Diserahkan oleh Diterima oleh
............................................. .............................................
.............................................................................................................................................
TANDA TERIMA
Kepada : ....................................................................................................................
Perihal : ....................................................................................................................
Dari : ..................................................................................................................
Alamat : ....................................................................................................................
....................................................................................................................
Jakarta, ..... .......... 2022
............................................. .............................................