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SURAT KETERANGAN

No : 18/0098/WER/123

1. Nama Lengkap : ..................................................................................................


2. Alamat Asal : ..................................................................................................
3. No. Dan tanggal KTP
: ..................................................................................................
4. Pindah ke : Desa/Kelurahan : ................................................................
Kecamatan : ................................................................
Kabupaten : ................................................................
Propinsi : ................................................................
Pada tanggal : ............Bulan....................Tahun...........
5. Alamat pindah : ..................................................................................................
6. Pengikut : ..................... orang yaitu :

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