PEMERINTAH KABUPATEN WONOGIRIKECAMATAN NGUNTORONADIKEPALA DESA WONOHARJOJl. Raya Wonogiri Pacitan KM 25 57671

SURAT KETERANGANNOMOR : ......................

Yang bertanda tangan di bawah ini menerangkan bahwa :Nama: ...................................................................................................Tempat tanggal lahir: ...................................................................................................Alamat: ...................................................................................................Pekerjaan: ...................................................................................................Kewarganegaraan: ...................................................................................................Status Perkawinan: ...................................................................................................Agama: ...................................................................................................No KK: ...................................................................................................NIK : ...................................................................................................Keperluan: ................................................................................................... ...................................................................................................Berlaku mulai: ........................................................ s/d ....................................Keterangan lain: ................................................................................................... ....................................................................................................Demikianlah surat keterangan ini dibuat dan kepada instansi terkait untuk memberikan pelayanan seperlunyaNomor:.................................Tanggal: .................................

MengetahuiWonoharjo, .................Pemegang suratCamat NguntoronadiKepala Desa Wonoharjo

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