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PERMOHONAN BANTUAN

Bidang/Jenis : ..................................................
A. DATA PEMOHON
Nama Pemohon : ...........................................................
Tempat/Tgl lahir : ...........................................................
Alamat Pemohon : ...............................................................................................
...............................................................................................
Paroki Pemohon : ...............................................................................................
Penanggungjawab Pemohon : ..................................................................................

B. ISI PERMOHONAN
Alasan permohonan : ...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
Bantuan yg dibutuhkan berupa:
1. Barang : ...............................................................................................
2. Biaya : Rp ......................................... (total)
Swadaya : Rp .........................................
Bantuan dari dansos paroki : Rp .........................................
Bantuan yg diminta ke APP Kevikepan : Rp .........................................

.............................., .................... 202...

............................................ ............................................ .......................................


Ketua Lingkungan Penanggungjawab Pemohon Pemohon

............................................ ......................................... ...........................................


Ketua PSE Rayon ...................... Pastor Paroki Ketua Tim Pel. PSE Paroki

Lampiran yang diperlukan :


1. Tagihan/rekening rumah sakit.
2. Surat edaran/tagihan dari sekolah
3. Analisa hasil usaha.
4. Foto Pendukung

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