RUKUN TETANGGA 005 / 03

KELURAHAN PETAMBURAN KECAMATAN TANAH ABANG

KOTA/KABUPATEN ADMINISTRASI JAKARTA PUSAT
Sekretariat : Jalan............................Tlp...............Faksimile..............E-mail.....................
Jakarta
Kode Pos 10260

SURAT PENGANTAR
NOMOR:

Yang bertandatangan dibawah ini, menerangkan bahwa :

Nama :..........................................................................................................

Tempat Tanggal Lahir :..........................................................................................................

Jenis Kelamin :..........................................................................................................

Agama :..........................................................................................................

Pekerjaan :..........................................................................................................

Alamat :..........................................................................................................

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Keperluan :..........................................................................................................

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Demikian surat pernyataan ini dubuat untuk dapat dipergunakan sebagaimana mestinya dan yang
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KETUA RW. 03 KETUA RT. 005 /03

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