1. Nama : ........................................................................................................
Umur : ........................................................................................................
Pekerjaan : ........................................................................................................
Alamat : ......................................................................................................
..................................................................................... .....................
Selanjutnya disebut Pihak Pertama
2. Nama : ........................................................................................................
Umur : ........................................................................................................
Pekerjaan : ........................................................................................................
Alamat : ........................................................................................................
........................................................................................................
Selanjutnya disebut Pihak Kedua
Demikian Surat Kuasa ini diberikan untuk dapat dipergunakan sebagaimana mestinya.
Kutabima, 2020
Pihak Kedua Pihak Pertama
Materai 6000
( ……………………………) ( …………………………..)
MENGETAHUI :
KEPALA DESA BENER
KECAMATAN MAJENANG
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