Nama : ................................................................................................................
Jenis Kelamin : Laki – laki / Perempuan
Tempat / Tgl Lahir : ................................................................................................................
Status Perkawinan : ................................................................................................................
Agama : ................................................................................................................
No. KTP / KK : ................................................................................................................
Pekerjaan : ................................................................................................................
Alamat (KTP) : .......................................................................... RT.......... / RW ...........
Kelurahan ..............................................................................................
.
Kecamatan.............................................................................................
Kota / Kabupaten ...................................................................................
Maksud / Tujuan : Ybs. benar warga kami yang bertempat tinggal di RT 004 / RW 002,
Gang F / Gang Jaim* dan bermaksud
untuk ..........................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
Jakarta, ............................
Ketua RT 004/002
Nomor : .......................................
Tgl : .......................................
Pengurus RW 002
(..................................)