Surat Keteranan RW/RT Taman Kapuk Permai

RT. 02 RW. 11 TAMAN KAPUK PERMAI

DESA KEDUNGJAYA KECAMATAN KEDAWUNG

KABUPATEN CIREBON

Nomor                  :  ………./SP-RT/………. /2016

Sifat                       :  Penting

Lampiran             :  --

Perihal                  :  SURAT PENGANTAR

                                                                                                                                                                Kepada Yth.

                                                                                                                                                                Bapak Kepala Desa Kedungjaya

                                                                                                                                                                Di-

                                                                                                                                                                                Tempat

Yang bertanda tangan dibawah ini Ketua RT. 02 / RW. 11 Taman Kapuk Permai, dengan ini menerangkan bahwa :

N a m a                                                 : ......................................................................................................................................

Tempat / Tanggal Lahir                  : ......................................................................................................................................

Golongan Darah                               : ......................................................................................................................................

Status Perkawinan                          : ......................................................................................................................................

Kebangsaan / Keturunan              : ......................................................................................................................................

Agama                                                  : ......................................................................................................................................

Pendidikan                                         : ......................................................................................................................................

Pekerjaan                                           : ......................................................................................................................................

A l a m a t                                             : ......................................................................................................................................

                                                                  Desa Kedungjaya Kecamatan Kedawung Kabupaten Cirebon

Adalah benar penduduk kami dan yang bersangkutan bermaksud :

........................................................................................................................................................................................................................................................................................................................................................................................

Demikian agar yang berkepentingan menjadi maklum adanya.

                                                                                                                                                                Cirebon, ....................................2016

Mengetahui, Ketua RW. 11 Taman Kapuk Permai No. ....../SP-RW/......./2016	Ketua RT. 02 Taman Kapuk Permai
Dr. Abdul Aziz, M.Ag	Dr.H.Tamsik Udin, M.Pd