Nomor : ......................................................................
Pada hari ini, ............................ tanggal ......... bulan ................... tahun .....................................,
Saya yang bertandatangan dibawah ini Orangtua/Suami/Istri/Anak*):
Nama : ..................................................................................................................
Tempat, Tanggal lahir : ..................................................................................................................
NIK : ..................................................................................................................
Alamat : ..................................................................................................................
..................................................................................................................
..................................................................................................................
No. Tlp/HP. : ..................................................................................................................
Dengan ini menyatakan dengan sebenar-benarnya bahwa saya memberikan ijin kepada
Orangtua/Suami/Istri/Anak*) dengan nama sebagai berikut:
Nama : ..................................................................................................................
Tempat, Tanggal lahir : ..................................................................................................................
NIK : ..................................................................................................................
Alamat : ..................................................................................................................
..................................................................................................................
..................................................................................................................
No. Tlp/HP. : ..................................................................................................................
Demikian surat keterangan izin ini dibuat agar dapat dipergunakan sebagaimana mestinya.
Tasikmalaya, .............................................
(___________________________) (___________________________)
Mengetahui,
Kepala Desa ....................................................
(___________________________)