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Formulir BOS 04

Dibuat oleh Madrasah danDikirim ke PPK Provinsi atau Kab/Kota

SURAT PERNYATAAN

PENGIRIMAN NOMOR REKENING MADRASAH

Pada hari ini, tanggal .......................... kami kirimkan salinan halaman pertamaBuku Tabungan Bank................................ alamat Bank .......................................................atas nama Madrasah :

Nama Madrasah : MTs Muhammadiyah 1 Ponorogo NSM : 1212 !"2"" #

$lamat Madrasah : %alan Stadion Timur No. 2"b&el'(esa &ertosari&e)amatan Babadan&ab'&ota. Ponorogo

No *ekening$tas Nama : 1. (rs. Muhammad +dris Septrianto, M.Pd %abatan &epala Sekolah

2. i-ik ntari %abatan Bendahara Nomor telepon yang bisa dihubungi /ika 0a yang kami kirimkan kurang /elas :1. No. ...............................................................Telp. ...........................................................................................................

2. No. ..............................................................Telp. ...........................................................................................................

. No. ..............................................................Telp. ...........................................................................................................

ang Mengirimkan

3 ........................................ 4

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