<h4 style="margin: 0; text-align: center;"><span style="text-decoration: underline;">[JUdul_surat]</span></h4>
<br>
<div style="text-align: justify;">Yang bertanda tangan di bawah ini :</div>
<table style="border-collapse: collapse; width: 100%; height: 106px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Nama Lengkap</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Tempat &amp; Tgl. Lahir</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[TtL]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Umur</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[UsiA]</td>
</tr>
<tr style="height: 19px;">
<td style="width: 4.51866%; text-align: center; height: 19px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 19px;">Pekerjaan</td>
<td style="width: 1.30976%; text-align: center; height: 19px;">:</td>
<td style="width: 62.4754%; height: 19px; text-align: justify;">[PekerjaaN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Nomor KTP</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[NiK]</td>
</tr>
<tr style="height: 15px;" valign="top">
<td style="width: 4.51866%; text-align: center; height: 15px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 15px;">Alamat</td>
<td style="width: 1.30976%; text-align: center; height: 15px;">:<br><br></td>
<td style="width: 62.4754%; height: 15px; text-align: justify;">[AlamaT] [Sebutan_desA] [Nama_desA], [Sebutan_kecamataN] [Nama_kecamataN], [Sebutan_kabupateN] [Nama_kabupateN]</td>
</tr>
</tbody>
</table>
<div style="text-align: justify;"><br>Dengan ini menyatakan bahwa saya dengan itikad baik telah menguasai sebidang tanah yang terletak :</div>
<table style="border-collapse: collapse; width: 100%; height: 162px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Jalan / RT</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[Form_jalaN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Dusun</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_rt_rW]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Desa/ Kelurahan</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[Form_desa_kelurahaN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Kecamatan</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_kecamataN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Kabupaten</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_kabupaten_kotA]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">NIB</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[Form_niB]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Status Tanah</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_status_tanaH]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Dipergunakan untuk</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[Form_dipergunakaN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Luas</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_luas_tanah_m2]</td>
</tr>
</tbody>
</table>
<div style="text-align: justify;"><br>Batas-Batas Tanah :</div>
<table style="border-collapse: collapse; width: 100%; height: 72px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Sebelah Utara</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[Form_batas_sebelah_utarA]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Sebelah Selatan</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_batas_sebelah_selataN]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Sebelah Timur</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; height: 18px; text-align: justify;">[Form_batas_sebelah_timuR]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.51866%; text-align: center; height: 18px;"> </td>
<td style="width: 31.7616%; text-align: left; height: 18px;">Sebelah Barat</td>
<td style="width: 1.30976%; text-align: center; height: 18px;">:</td>
<td style="width: 62.4754%; text-align: justify; height: 18px;">[Form_batas_sebelah_baraT]</td>
</tr>
</tbody>
</table>
<div style="text-align: justify;"><br>Bidang Tanah tersebut saya peroleh dari [Form_tanah_diperoleh_dari_] tahun [Form_diperoleh_sejak_tahuN] dengan jalan [Form_jalaN] / terlampir yang sampai saat ini saya kuasai secara terus menerus dan</div>
<table style="border-collapse: collapse; width: 100%; height: 89.5624px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 3.0303%; height: 22.3906px; text-align: right;">-</td>
<td style="width: 1.77693%; text-align: left; height: 22.3906px;"> </td>
<td style="width: 95.1928%; height: 22.3906px; text-align: justify;">Tidak diajukan/ menjadi jaminan hutang</td>
</tr>
<tr style="height: 18px;">
<td style="width: 3.0303%; height: 22.3906px; text-align: right;">-</td>
<td style="width: 1.77693%; text-align: left; height: 22.3906px;"> </td>
<td style="width: 95.1928%; height: 22.3906px; text-align: justify;">Tidak dalam keadaan sengketa</td>
</tr>
<tr style="height: 18px;">
<td style="width: 3.0303%; height: 22.3906px; text-align: right;">-</td>
<td style="width: 1.77693%; text-align: left; height: 22.3906px;"> </td>
<td style="width: 95.1928%; height: 22.3906px; text-align: justify;">Tidak merupakan tanah warisan yang belum di bagi</td>
</tr>
<tr style="height: 18px;">
<td style="width: 3.0303%; height: 22.3906px; text-align: right;">-</td>
<td style="width: 1.77693%; text-align: left; height: 22.3906px;"> </td>
<td style="width: 95.1928%; height: 22.3906px; text-align: justify;">Belum bersertifikat</td>
</tr>
<tr style="height: 18px;">
<td style="width: 3.0303%; text-align: right;">-</td>
<td style="width: 1.77693%; text-align: left;"> </td>
<td style="width: 95.1928%; text-align: justify;">Penggunaannya tidak pernah di ganggu gugat</td>
</tr>
</tbody>
</table>
<div style="text-align: justify;"><br>Surat pernyataan ini saya bubuhkan cap jempol setelah saya dibacakan dan mengerti isi/ maksud, dibuat dengan sebenarnya dengan penuh tanggung jawab dan saya bersedia untuk mengangkat sumpah bila diperlukan.<br><br>Demikian dan apabila ini tidak benar, saya bersedia dituntut di hadapan pihak berwenang.<br><br>SAKSI-SAKSI</div>
<table style="border-collapse: collapse; width: 100%; height: 208px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; height: 18px; text-align: left;">1.</td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Nama</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; height: 18px; text-align: justify;">[Nama_saksi_I]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Umur</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;">[Usia_saksi_I]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; height: 18px; text-align: left;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Pekerjaan</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; height: 18px; text-align: justify;">[Pekerjaan_saksi_I]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Alamat</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;">[Alamat_saksi_I]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Tanda Tangan</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;"> </td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; height: 18px; text-align: left;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;"> </td>
<td style="width: 1.24427%; text-align: center; height: 18px;"> </td>
<td style="width: 59.9869%; height: 18px; text-align: justify;"> </td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;">2.</td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Nama</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;">[Nama_saksi_iI]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; height: 18px; text-align: left;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Umur</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; height: 18px; text-align: justify;">[Usia_saksi_iI]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Pekerjaan</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;">[Pekerjaan_saksi_iI]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Alamat</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;">[Alamat_saksi_iI]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 18px;">Tanda Tangan</td>
<td style="width: 1.24427%; text-align: center; height: 18px;">:</td>
<td style="width: 59.9869%; text-align: justify; height: 18px;"> </td>
</tr>
<tr style="height: 10px;">
<td style="width: 4.3222%; text-align: center; height: 10px;"> </td>
<td style="width: 3.92927%; text-align: left; height: 10px;"> </td>
<td style="width: 30.5174%; text-align: left; height: 10px;"> </td>
<td style="width: 1.24427%; text-align: center; height: 10px;"> </td>
<td style="width: 59.9869%; text-align: justify; height: 10px;"> </td>
</tr>
</tbody>
</table>
<table style="border-collapse: collapse; width: 100%; height: 180px;" border="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;"> </td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;"> </td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;">Reg No: ____________________</td>
<td style="width: 30%; height: 18px; text-align: center;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">[NaMa_desa], [TgL_surat]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;">Tanggal : ____________________</td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">Hormat Kami,</td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;">Mengetahui / Membenarkan</td>
<td style="width: 30%; height: 18px; text-align: center;">[qr_code]</td>
<td style="width: 35%; text-align: center; height: 18px;"> </td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;">[Sebutan_kepala_desA] [Nama_desA]</td>
<td style="width: 30%; height: 18px; text-align: center;"> </td>
<td style="width: 35%; text-align: center; height: 18px;"> </td>
</tr>
<tr style="height: 54px;">
<td style="width: 35%; text-align: center; height: 54px;"> </td>
<td style="width: 30%; height: 54px;"> </td>
<td style="width: 35%; height: 54px;"> </td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;">[Nama_pamonG]</td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">[NamA]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; height: 18px;"> </td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;"> </td>
</tr>
</tbody>
</table>
<div style="text-align: center;"><br><br></div>