RUKUN TETANGGA (RT)
PERUMAHAN MURIA INDAH RW 014
DEWA MIJEN, KECAMATAN KALIWUNGU
KABUPATEN KUDUS – JAWA TENGAH, KODE POS 59319
LAMPIRAN XII : Model AA.04
SURAT PENGANTAR
No. ...............................................
Yang bertanda tangan di bawah ini, Pengurus RT.... / RW....., Desa Cikahuripan, Kecamatan Klapanunggal, Kabupaten Bogor dengan ini menerangkan bahwa :
Nama : .............................................................................................................
Jenis Kelamin : .............................................................................................................
Tempat/Tgl. Lahir : .............................................................................................................
Pekerjaan : .............................................................................................................
No.KTP/KK : .............................................................................................................
Kewarganegaraan : .............................................................................................................
Pendidikan : .............................................................................................................
Agama : .............................................................................................................
Alamat : .............................................................................................................
RT............................./ RW ........................
Maksud Keperluan : .............................................................................................................
.............................................................................................................
.............................................................................................................
Nomor : ...................... Mijen, ...................................
Mengetahui , Pengurus RT .... / RW......
Pengurus RW 014 Ketua,
(....................................) (...................................)
