Jakarta,

Kepada Yth.
BADAN PELAKSANA ZAKAT, INFAK, SEDEKAH DAN WAKAF

YAYASAN BAITULMAL UMMAT ISLAM

BANK NEGARA INDONESIA (BAMUIS BNI)
Jl. Percetakan Negara VII No. 3C
Rawasari Jakarta Pusat 10570
SURAT PERMOHONAN
PROGRAM PEMBERDAYAAN EKONOMI DHUAFA
( diisi dengan tanda pada yang sesuai/dipilih)

Assalamu’alaikum Wr. Wb.

Bantuan yang dimohon sebesar Rp. .............................................. ( .................................................................... ) yang akan dipergunakan untuk keperluan :

Pembelian Sarana/peralatan usaha (lampiran rincian jenis sarana/peralatan & perkiraan : Rp. ............................................................................
Perbaikan tempat usaha (lampirkan rencana biaya) ....................................................................................... : Rp. ............................................................................
Modal kerja / tambahan modal kerja (rincian terlampir) ............................................................................... : Rp. ............................................................................
Lain - lain (terlampir) ................................................................................................................................................................. : Rp. ............................................................................

I. DATA PEMOHON*
1. Nama Pemohon : .................................................................................................................. Email : ...........................................................................................................
2. Istri / Suami dari : ..................................................................................................................................................................................................................................................
3. Tempat / tanggal lahir : ..................................................................................................................................................................................................................................................
4. Alamat rumah : ..................................................................................................................................................................................................................................................
Kode Pos : ................................. Telp. Rumah : ................................................... No. Hp. : ............................................................................
5. Agama : ..................................................................................................................................................................................................................................................
6. Status : Pensiunan BNI (lampirkan fotocopy Kartu Dana Pensiunan)
Masyarkat Umum
Pegawai Anak Perusahaan BNI / Lembaga BNI
(terlampir fotocopy KTP dan SK Pegawai)
Pegawai BNI (lampirkan Fotocopy TPP)

7. Jumlah penghasilan bruto rata-rata per bulan

a. Gaji / Pensiunan / Pendapatan lain : Rp. ............................................................................................................................................................
b. Penghasilan Usaha Suami / Istri : Rp. ............................................................................................................................................................
c. Penghasilan lainnya (lampirkan slip gaji /pensiunan) : Rp. ............................................................................................................................................................
8. Jumlah anak / tanggungan : ........................... orang (lampirkan fotocopy Kartu Keluarga)
9. Alamat lokasi tempat usaha : ....................................................................................................................................................................
.....................................................................................................................................................................
Kode Pos : ...................................................... Telp. Rumah : ..................................................
No. Hp : ..................................................................................................................................................
10. Jenis usaha kecil yang dikelola : ....................................................................................................................................................................
11. Pengalaman usaha : ............................................................... Tahun ...................................................................................
12. Pengalaman / masa kerja di : ............................................................... Tahun ...................................................................................
13. Penghasilan usaha rata-rata per bulan bila modal ditambah : ....................................................................................................................................................................
14. Bank dan Nomor Rekening : Bank : .................................................... Cabang/KCP : ..........................................................
No. Rekening : ............................................................ a.n. : ........................................................

Wassalamu’alaikum Wr. Wb.

II. REKOMENDATOR*
MENGETAHUI & MENDUKUNG PEMOHON : Jakarta, ........................................, 20 .....
PIMPINAN BNI / PENGURUS Yang mengajukan/ mengetahui,
PERSATUAN PENSIUNAN BNI / Rekomendator

( ................................................................ ) ( ................................................................ ) ( ................................................................ )

Nama Jelas & Stempel Nama Pemohon Suami/Istri
(Bagi Perusahaan/ Lembaga)

Lampiran :

KTP
Kartu Keluarga
Surat Keterangan Tidak Mampu (SKTM)
Surat lainnya

Noted: *) Wajib diisi