Tanggal, …..................... Sudah Terima Dari : ….................................. Sudah Terima Dari : …............................................................................................................................................................ ….................................. Uang Sejumlah : Uang Sejumlah : ….................................. ….................................. Untuk Pembayaran : …............................................................................................................................................................ Untuk Pembayaran : …............................................................................................................................................................ ….................................. …............................................................................................................................................................ ….................................. ….................................. …..............., ….............................,20…..... Rp