<h4 style="margin: 0; text-align: center;"><span style="text-decoration: underline;">[JUdul_surat]</span></h4>
<p style="margin: 0; text-align: center;">Nomor : [Format_nomor_suraT]<br><br></p>
<p style="text-align: justify;">      Yang bertanda tangan di bawah ini [Jabatan] [Nama_desa], Kecamatan [Nama_kecamatan], [Sebutan_kabupaten] [Nama_kabupaten], Provinsi [Nama_provinsi] menerangkan dengan sebenarnya bahwa :</p>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">1.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Nama</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;"><strong>[NAma]</strong></td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">2.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Tempat/tanggal lahir</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[TtL]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">3.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Umur</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[UsIa]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">4.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Warga negara</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[WArga_negara]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">5.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Agama</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[AgAma]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">6.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[JeNis_kelamin]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">7.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[Pekerjaan]</td>
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<td style="width: 5%; text-align: center; height: 36px; vertical-align: top;">8.</td>
<td style="width: 33.773%; text-align: left; height: 36px; vertical-align: top;">Tempat tinggal</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 36px; vertical-align: top;">[AlamaT] [Sebutan_desa] [Nama_desa], Kecamatan [Nama_kecamatan], [Sebutan_kabupaten] [Nama_kabupaten]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">9.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Surat bukti diri</td>
<td style="width: 1.22703%; text-align: left; vertical-align: top;"> </td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;"> </td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">KTP</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[Nik]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">KK</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">[No_kk]</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">10.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Keperluan</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">Permohonan Perubahan Kartu Keluarga WNI.</td>
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<td style="width: 5%; text-align: center; height: 18px; vertical-align: top;">11.</td>
<td style="width: 33.773%; text-align: left; height: 18px; vertical-align: top;">Keterangan lain-lain</td>
<td style="width: 1.22703%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60%; text-align: left; height: 18px; vertical-align: top;">Orang tersebut di atas adalah benar benar penduduk desa kami dan adat istiadat baik.</td>
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<p style="text-align: justify;">             </p>
<p style="text-align: justify; text-indent: 30px;">Demikian surat ini dibuat, untuk dipergunakan sebagaimana mestinya.<br><br></p>
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<td style="width: 35.0462%; text-align: center; height: 18px;"> </td>
<td style="width: 30.0103%; height: 18px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 18px;">[NaMa_desa], [TgL_surat]</td>
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<td style="width: 35.0462%; text-align: center; height: 18px;">Pemegang Surat</td>
<td style="width: 30.0103%; height: 18px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 18px;">[Atas_namA]</td>
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<tr style="height: 72px;">
<td style="width: 35.0462%; text-align: center; height: 72px;"> </td>
<td style="width: 30.0103%; height: 72px;"><br><br><br><br></td>
<td style="width: 35.0462%; height: 72px;"> </td>
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<tr style="height: 18px;">
<td style="width: 35.0462%; text-align: center; height: 18px;"><strong>[NAma]</strong></td>
<td style="width: 30.0103%; height: 18px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 18px;">[Nama_pamonG]</td>
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<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; height: 18px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 18px;">[SEbutan_nip_desa] : [nip_pamong]</td>
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<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; height: 18px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 18px;"> </td>
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<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; height: 18px;">No</td>
<td style="width: 35.0462%; text-align: left; height: 18px;">:</td>
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<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; height: 18px;">Tanggal</td>
<td style="width: 35.0462%; text-align: left; height: 18px;">:</td>
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<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; text-align: center; height: 18px;">Mengetahui,</td>
<td style="width: 35.0462%; text-align: left; height: 18px;"> </td>
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<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; text-align: center; height: 18px;">Camat - [NaMa_kecamatan]</td>
<td style="width: 35.0462%; text-align: left; height: 18px;"> </td>
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<td style="height: 72px; width: 35.0462%;" rowspan="2">[qr_code]</td>
<td style="width: 30.0103%; height: 72px;"><br><br><br></td>
<td style="width: 35.0462%; text-align: left; height: 72px;"> </td>
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<td style="width: 30.0103%; text-align: center; height: 18px;">..............................................</td>
<td style="width: 35.0462%; text-align: left; height: 18px;"> </td>
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<div style="text-align: center;"> </div>