PENGURUS RUKUN TETANGGA 000 / 00
KELURAHAN
KECAMATAN
KOTA ADMINISTRASI
SURAT PENGANTAR
NO. ...... / ................
Yang bertanda tangan di bawah ini Ketua RT .... / RW ..... Kelurahan
Susukan Kecamatan Ciracas Kota Administrasi Jakarta Timur menerangkan bahwa :
Nama Lengkap :
.....................................................................................
Jenis Kelamin :
Laki-laki / Perempuan
Tempat / Tgl.
Lahir :
.....................................................................................
No. KTP / KK :
......................................................................................
Kewarganegaraan :
......................................................................................
Agama :
.....................................................................................
Pekerjaan :
.....................................................................................
Alamat : .....................................................................................
.....................................................................................
Maksud /
keperluan : .....................................................................................
.....................................................................................
.....................................................................................
Nomor :
............................ Mataram,
..........................
Mengetahui
Pengurus RT ....... / ......
Pengurus RW .......
Stempel
(....................................)
(......................................)
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