<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; text-indent: 30px;">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: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;"><strong>[NAma]</strong></td>
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<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">NIK / No. KTP</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Nik]</td>
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<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">3.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[TtL]</td>
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<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">4.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Jenis_kelamin]</td>
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<tr style="height: 36px;">
<td style="width: 4.31655%; text-align: center; height: 36px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 36px; text-align: left; vertical-align: top;">5.<br><br></td>
<td style="width: 30.5242%; text-align: left; height: 36px; vertical-align: top;">Alamat / Tempat Tinggal<br><br></td>
<td style="width: 1.2333%; text-align: center; height: 36px; vertical-align: top;">:<br><br></td>
<td style="width: 60.0206%; height: 36px; text-align: justify; vertical-align: top;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
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<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">6.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[AgAma]</td>
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<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">7.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Status</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Status_kawin]</td>
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<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">8.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[PeKerjaan]</td>
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<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">9.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.2333%; height: 18px; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[WArga_negara]</td>
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<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">10.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Tujuan</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Form_tujuaN]</td>
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<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">11.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Keperluan</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Form_keperluaN]</td>
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<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left; vertical-align: top;">12.</td>
<td style="width: 30.5242%; text-align: left; height: 18px; vertical-align: top;">Berlaku</td>
<td style="width: 1.2333%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify; vertical-align: top;">[Mulai_berlaku] sampai dengan [Berlaku_sampai]</td>
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<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya, untuk dipergunakan sebagaimana mestinya.<br><br></p>
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<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[NaMa_desa], [TgL_surat]</td>
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<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Atas_namA]</td>
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<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"><br><br><br><br></td>
<td style="width: 35%;"> </td>
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<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Nama_pamonG]</td>
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<td style="width: 35%;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[SEbutan_nip_desa] : [nip_pamong]</td>
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<div style="text-align: center;"><br>[qr_code]</div>