Nama : .........................................................................................................
Alamat : .........................................................................................................
: .........................................................................................................
Pekerjaan : .........................................................................................................
Rp..............................
Demikian surat keterangan ini kami buat dengan sebenar-benarnya dan dapat
dipertanggungjawabkan.
......................................., .........../........./........
Materai Rp.10.000,-
(...................................................)