1. Nama : ......................................................................................
Alamat : ......................................................................................
Bertetangga sebelah : ......................................................................................
2. Nama : ......................................................................................
Alamat : ......................................................................................
Bertetangga sebelah : ......................................................................................
3. Nama : ......................................................................................
Alamat : ......................................................................................
Bertetangga sebelah : ......................................................................................
4. Nama : ......................................................................................
Alamat : ......................................................................................
Bertetangga sebelah : ......................................................................................
5. Nama : ......................................................................................
Alamat : ......................................................................................
Bertetangga sebelah : ......................................................................................
Demikian surat pernyataan ini kami buat dengan penuh kesadaran dan rasa
tanggungjawab. Atas perhatiannya, kami ucapkan terimakasih.
Lampegan, ............................
Yang Menyatakan,
1.......................................
2......................................
,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
3......................................
4.....................................
5......................................
Mengetahui Ket Rt Mengetahui Ket Rw
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