SURAT PERNYATAAN PEMOTONGAN KOPERASI KESKAR

RSU MOHAMMAD NOER PAMEKASAN PADA GAJI DAN

JASA PELAYANAN

Dengan ini menyatakan dengan sesungguhnya bahwa kami yang bertanda tangan dibawah ini adalah
anggota Koperasi Keskar RSU Mohammad Noer Pamekasan yang mempunyai kewajiban untuk membayar
uang simpanan wajib, dana sosial, pokok sp, jasa sp serta tabungan hari raya yang dibayarkan setiap bulan
pada pendapatan kami yang sah berupa Gaji dan Jasa Pelayanan.

Dengan surat ini pernyataan ini kami bersedia untuk dilakukan pemotongan dengan jumlah sebagaimana
tersebut dibawah ini.

Demikian surat pernyataan ini untuk dipergunakan sebagai mestinya.

 SIMP DANA
NO NAMA TAHARA POKOK SP JASA SP ANGSURAN JUMLAH TTD
WAJIB SOSIAL

1 Suwardi 100,000 2,500 20,000 1,500,000 300,000 15 1,922,500 20x

2 Dinawati, S.Kep.,NS 100,000 2,500 500,000 600,000 2 1,202,500 30x

3 Sakur, Amr 100,000 2,500 1,000,000 1,000,000 300,000 15 2,402,500 30x

4 Andarwati 100,000 2,500 25,000 1,000,000 300,000 14 1,427,500 30x

5 Halili 100,000 2,500 50,000 2,334,000 700,000 12 3,186,500 30x

6 Mohammad Yasif, S.Kep.,Ns 100,000 2,500 500,000 2,334,000 700,000 18 3,636,500 30x

7 Mohamad Arifin,S.Sos., M.IP 100,000 2,500 500,000 600,000 8 1,202,500 20x

8 Sri Hartatik H, S.Kep.,Ns 100,000 2,500 1,000,000 1,667,000 500,000 21 3,269,500 30x

9 dr. David Alvianto 100,000 2,500 100,000 202,500

10 dr. Wiwiet Widowati Agustiani 100,000 2,500 500,000 2,600,000 7 3,202,500 30x

11 Suyoto, Amd.Kep 100,000 2,500 100,000 202,500

12 Sayuri 100,000 2,500 200,000 302,500

13 Suswalinda, Amak 100,000 2,500 500,000 800,000 1 1,402,500 30x

14 Lilik Widiartini, Amd.Kes 100,000 2,500 250,000 2,000,000 600,000 16 2,952,500 30x

15 Sarifudin, S.Kep., Ns 100,000 2,500 200,000 1,000,000 300,000 17 1,602,500 30x

16 Hanis Maulana 100,000 2,500 500,000 2,800,000 6 3,402,500 30x

17 Mohammad Kasih 100,000 2,500 400,000 2,334,000 700,000 14 3,536,500 30x

18 Ayu Dewi Ning Tias, Amd.Kep 100,000 2,500 200,000 2,800,000 9 3,102,500 30x

19 Yustina Des Brawijayati, Amd.Kep 100,000 2,500 400,000 1,000,000 300,000 15 1,802,500 30x

20 Ach. Hardiyanto 100,000 2,500 25,000 300,000 3 427,500 10x

21 Ika Rachmawati Apri Yani, Amak 100,000 2,500 200,000 500,000 100,000 16 902,500 20x

22 Ainur Rahman 100,000 2,500 300,000 402,500

23 Vina Indira Wardhani, SE 100,000 2,500 1,000,000 600,000 3 1,702,500 5x

24 Nanang Sumardiyanto, Amd.Kep 100,000 2,500 100,000 202,500

25 Lestari Wijihastuti, SE 100,000 2,500 1,000,000 1,200,000 2 2,302,500 30x

26 Fita Widayati, Amd.Ak 100,000 2,500 600,000 2,000,000 4 2,702,500 30x

27 Ginanjar Rah Utomo, Amd.Kep 100,000 2,500 400,000 502,500

28 Afan Asmara Yudha, S.Si 100,000 2,500 250,000 660,000 10 1,012,500 20x

29 Fadillah 100,000 2,500 250,000 600,000 10 952,500 30x

30 Sudiyanto 100,000 2,500 100,000 1,000,000 200,000 16 1,402,500 20x

31 Nur Aini 100,000 2,500 100,000 1,400,000 1 1,602,500 30x

32 Yuli Setiana Rahayu, SE 100,000 2,500 1,000,000 1,102,500

33 Hendra Lutfiadi, Amd. Kep 100,000 2,500 600,000 702,500

34 Achmad Danafia Moenir, SE 100,000 2,500 100,000 2,800,000 5 3,002,500 30x

35 Erik Supriadi, Amd.Kep 100,000 2,500 250,000 352,500

36 Moh. Hanafi Budi Cahyono, Amd.Kep 100,000 2,500 100,000 202,500

37 Ach. Kusairi, Amd.Kep 100,000 2,500 200,000 500,000 100,000 13 902,500 20x

38 Maisaroh, Amd.Kep 100,000 2,500 300,000 402,500

39 Sitti Amina, Amd.Kep 100,000 2,500 400,000 300,000 3 802,500 10x

40 Yudi Septian Dwi Cahyono, Amd.Kep 100,000 2,500 300,000 402,500

41 Johan Wahyudi, Amd.Kep 100,000 2,500 100,000 202,500

42 Zainal Abrori, Amd.Kep 100,000 2,500 300,000 600,000 120,000 13 1,122,500 20x

43 Sudarli, Amd.Kep 100,000 2,500 200,000 302,500

44 Ulivatul Wardiyyah, S.KM 100,000 2,500 250,000 352,500

45 Akhmad Kuzairi 100,000 2,500 300,000 402,500

46 Ulva Rosyana, S.Farm.Apt 100,000 2,500 1,000,000 1,102,500

47 Yogi Agustian 100,000 2,500 350,000 300,000 3 752,500 10x

48 Moh. Tohed Efendi 100,000 2,500 200,000 600,000 1 902,500 30x

49 Sumaji Maryono 100,000 2,500 200,000 600,000 8 902,500 20x

50 Dwi Indah Purnamasari, S.Kep.,Ns 100,000 2,500 300,000 402,500

51 Lisdiawati, Amd.Kep 100,000 2,500 700,000 802,500

52 Hikmatul Maulidiyah, Amd.Kep 100,000 2,500 200,000 300,000 5 602,500 20x

53 Mohammad Efendi 100,000 2,500 200,000 2,000,000 5 2,302,500 30x

54 dr. Mohammad Husni Thamrin 100,000 2,500 102,500

55 Lutfi Lindawati 100,000 2,500 900,000 300,000 2 1,302,500 10x

56 Alif Surya Putra Wijaya 100,000 2,500 200,000 300,000 6 602,500 10x

57 Akh. Azis Albar, Amd.Kep 100,000 2,500 100,000 1,175,160 8 1,377,660 30x

58 Doni Febriyanto,Amd.Kep 100,000 2,500 1,000,000 1,102,500

59 Hesti Rusdiatul Fatatik P, Amd.Kep 100,000 2,500 400,000 502,500

60 M. Bayu Wicaksono, Amd.Kep 100,000 2,500 300,000 402,500

61 Mohammad Firman A, Amd.Kep 100,000 2,500 500,000 602,500

62 Edy Sulkarnaen 100,000 2,500 50,000 1,200,000 9 1,352,500 30x

63 Sitta Ekawati Praptini, Amd.Kep 100,000 2,500 300,000 300,000 3 702,500 10x

64 Robiatun, Amd.Kep 100,000 2,500 300,000 402,500

65 Sahid 100,000 2,500 50,000 480,000 4 632,500 10x

66 Rizal 100,000 2,500 50,000 300,000 4 452,500 10x

67 Siti Hosniyah, Amd.Kep 100,000 2,500 400,000 502,500

68 Citra Hari Perdana, Amd.Kep 100,000 2,500 150,000 800,000 7 1,052,500 30x

69 Abdi Sodhaq 100,000 2,500 200,000 302,500

70 dr. Aprilia Romdiyana 100,000 2,500 1,000,000 1,102,500

71 Akhmad Taufik Hidayat, Amd.Kep 100,000 2,500 100,000 202,500

72 Astri Normalasari, Amd.Kep 100,000 2,500 200,000 302,500

73 Eva Fitriyah, Amd.Kep 100,000 2,500 200,000 302,500

74 Abdul Rahman Triyanto, Amd.Kep 100,000 2,500 100,000 202,500

75 Abdul Anam, Amd.Kep 100,000 2,500 300,000 402,500

76 Desi Arisandi, Amd.Kep 100,000 2,500 300,000 402,500

77 Misbahul Munir, Amd.Kep 100,000 2,500 500,000 602,500

78 Dewi Yuniartin, Amd.Kep 100,000 2,500 750,000 852,500

79 Khalifatur Rahmah, Amd.Kep 100,000 2,500 500,000 602,500

80 Ach. Firman Zuhdi, Amd.Kep 100,000 2,500 400,000 300,000 8 802,500 10x

81 Rosita Dewi Handiyana, Amd.Kep 100,000 2,500 300,000 402,500

82 Firdaus Watun Hasanah, Amd.Kep 100,000 2,500 250,000 400,000 40,000 14 792,500 20x

83 Ach. Zainal Arifin, Amd.Kep 100,000 2,500 500,000 602,500

84 Yunita Ayu Pratiwi, Amd.Rad 100,000 2,500 250,000 300,000 5 652,500 10x
 100,00
85 Noviyanto Budi Dewadji, Amd.Kep 100,000 2,500 0 1,200,000 3 1,402,500 30x

86 Bambang Andy Suharto, Amd.TEM 100,000 2,500 250,000 2,000,000 3 2,352,500 30x

87 Widodo Dwi Nurcahyo, Amd.Kep 100,000 2,500 500,000 602,500

88 Ika Mery Aninda, Amd.Kep 100,000 2,500 100,000 1,400,000 3 1,602,500 20x

89 Ikhwan Fanani Marwi, SE 100,000 2,500 200,000 302,500

90 dr. Dian Puspitarini, Sp.S 100,000 2,500 1,000,000 1,102,500

91 dr. Radhitya Farizky Deta Juniawan 100,000 2,500 50,000 152,500

92 Fatika Oczaldila, SKM 100,000 2,500 300,000 402,500

93 R. Restu Putri Wulandari, SE 100,000 2,500 150,000 500,000 150,000 15 902,500 30x

94 Zainuddin Chandra Prasetia, Amd.Kep 100,000 2,500 100,000 202,500

95 Moch. Joko Wediarto, Amd.Kep 100,000 2,500 200,000 300,000 10 602,500 10x

96 Imam Baihaki, Amd.Kep 100,000 2,500 200,000 302,500

97 Herlan Adinata, Amd.Kep 100,000 2,500 750,000 852,500

98 Ike Dwi Herdayanti, Amd.Kep 100,000 2,500 400,000 502,500

99 Rusliyana, Amd.AK 100,000 2,500 500,000 602,500

100 Nika Prihandini, Amd.AK 100,000 2,500 300,000 402,500

101 Fian Andika Novianto, Amd.Kep 100,000 2,500 250,000 800,000 8 1,152,500 30x
102 Karimullah, Amd.Kep 100,000 2,500 200,000 302,500

103 Iwan Feri Haryanto, Amd.Kep 100,000 2,500 300,000 250,000 50,000 16 702,500 20x

104 Abd Hayyi, Amd.Kep 100,000 2,500 100,000 500,000 100,000 12 802,500 20x

105 Dedy Haryanto, Amd.Kep 100,000 2,500 150,000 252,500

106 Ririn Fitriana, Amd.Kep 100,000 2,500 500,000 602,500

107 Nur Fajri Aprelia, Amd.Kep 100,000 2,500 800,000 902,500

108 Akhmad Faiq Sutanto, Amd.Kep 100,000 2,500 250,000 300,000 5 652,500 10x

109 Dhahekah, Amd.Keb 100,000 2,500 500,000 602,500

110 Fitradiyah Aprianti, Amd.Keb 100,000 2,500 500,000 602,500

111 Zhulvie Meylanzharie, Amd.Keb 100,000 2,500 400,000 502,500

112 Sahrotun, Amd.Keb 100,000 2,500 350,000 452,500

113 Sulaiman 100,000 2,500 100,000 600,000 4 802,500 20x

114 Moh. Tohir, Amd.Kep 100,000 2,500 100,000 500,000 100,000 12 802,500 20x

115 R. Sugesti Handayani, S.Farm.Apt 100,000 2,500 500,000 200,000 6 802,500 10x

116 Siti Qorimah, Amd.Kep. 100,000 2,500 500,000 602,500

117 Suhartono Ariyanto, S.Kep.Ns 100,000 2,500 500,000 602,500

118 Ach. Rochihan Bahtiar, A.Md. RMIK 100,000 2,500 250,000 352,500
119 Elde Alifi Subhan Syadad, A.Md.Rad 100,000 2,500 500,000 300,000 5 902,500 10x

120 Yuli Astutik, Amd.Kep. 100,000 2,500 300,000 402,500

121 Moh. Fauzi 100,000 2,500 50,000 600,000 5 752,500 10x

122 Rika Anggraini Irawan, A.Md 100,000 2,500 100,000 202,500

123 Faizatul Mukarromah, A.Md.Farm 100,000 2,500 100,000 202,500

124 Rintih Hestiati, Amd. Kep 100,000 2,500 200,000 302,500

125 Ach. Hadiyatullah 100,000 2,500 200,000 800,000 4 1,102,500 30x

126 dr. Zakiyah Zulfa 100,000 2,500 1,000,000 2,400,000 2 3,502,500 10x

127 dr. Deddy Fransieska 100,000 2,500 500,000 602,500

128 Suciati Nuraini, Amd.RMIK 100,000 2,500 100,000 202,500

129 Hidhayatul Rizkiyani, Amd.Ak 100,000 2,500 100,000 202,500

130 Rizki Maulana Ilyas, Amd. Ak 100,000 2,500 100,000 202,500

131 Abdullah Hidayah 100,000 2,500 200,000 302,500

132 Massus, Amd.Kep 100,000 2,500 250,000 352,500

133 Mochammad Firdiansyah Dio S. 100,000 2,500 100,000 202,500

13,300,00 332,50 44,520,00 61,134,16 5,660,00 124,946,66
TOTAL 0 0 0 0 0 0