<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;">YDengan ini kami mengajukan orang untuk mengadakan [Judul_suraT] seperti tersebut di bawah ini  :</p>
<table style="border-collapse: collapse; width: 100%; height: 481.547px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[NiK]</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">3.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Jenis Kelamin / Agama</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[Jenis_kelamiN] / [AgamA]</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">4.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[AlamaT]</td>
</tr>
<tr style="height: 39.75px;">
<td style="width: 4.33944%; text-align: center; height: 39.75px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 39.75px; text-align: left; vertical-align: top;"> </td>
<td style="width: 30.5207%; text-align: left; height: 39.75px; vertical-align: top;"><strong><br>Telah Lahir Pada :</strong></td>
<td style="width: 1.30183%; text-align: center; height: 39.75px; vertical-align: top;"> </td>
<td style="width: 60.0289%; height: 39.75px; text-align: justify; vertical-align: top;"> </td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">5.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Hari, Tanggal, Pukul</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[HaRi_kelahiran], [TaNggal_kelahiran], [JaM_kelahiran] WIB</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">6.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Bertempat di</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[TeMpat_dilahirkan]</td>
</tr>
<tr style="height: 19.375px;">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;"> </td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;"><strong><br>Dengan orang tua</strong>:</td>
<td style="width: 1.30183%; height: 19.375px; text-align: center; vertical-align: top;"> </td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;"> </td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">7.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Nama Ibu</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[NAma_ibu]</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">8.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">NIK / Tanggal Lahir Ibu</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[Nik_ibU] / [Tempatlahir_ibU]</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">9.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Pekerjaan Ibu</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[Pekerjaan_ibU]</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.375px; text-align: left; vertical-align: top;">10.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Alamat Ibu</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.375px; text-align: justify; vertical-align: top;">[Alamat_ibU] [Sebutan_desA] [Nama_desA], [Sebutan_kecamataN] [Nama_kecamataN], [Sebutan_kabupateN] [Nama_kabupateN]</td>
</tr>
<tr style="height: 19.4219px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.4219px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 19.4219px; text-align: left; vertical-align: top;">11.</td>
<td style="width: 30.5207%; text-align: left; height: 19.4219px; vertical-align: top;">Nama Ayah</td>
<td style="width: 1.30183%; text-align: center; height: 19.4219px; vertical-align: top;">:</td>
<td style="width: 60.0289%; height: 19.4219px; text-align: justify; vertical-align: top;">[NAma_ayah]</td>
</tr>
<tr style="height: 19.2344px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;">12.</td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;">NIK / Tanggal Lahir Ayah</td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;">[Nik_ayaH] / [Tanggallahir_ayaH]</td>
</tr>
<tr style="height: 19.2344px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;">13.</td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;">Pekerjaan Ayah</td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;">[Pekerjaan_ayaH] </td>
</tr>
<tr style="height: 36px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 36px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 36px; vertical-align: top;">14.</td>
<td style="width: 30.5207%; text-align: left; height: 36px; vertical-align: top;">Alamat Ayah</td>
<td style="width: 1.30183%; text-align: center; height: 36px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 36px; vertical-align: top;">[Alamat_ayaH] [Sebutan_desA] [Nama_desA], [Sebutan_kecamataN] [Nama_kecamataN], [Sebutan_kabupateN] [Nama_kabupateN]</td>
</tr>
<tr style="height: 19.2344px;">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;"> </td>
</tr>
<tr style="height: 19.2344px;">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="text-align: left; height: 19.2344px; width: 95.757%; vertical-align: top;" colspan="4">Surat Keterangan ini dibuat berdasarkan keterangan pelapor:</td>
</tr>
<tr style="height: 19.2344px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;">15.</td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;">[NAma_pelapor]</td>
</tr>
<tr style="height: 19.2344px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;">16.</td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;">NIK / Jenis Kelamin</td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;">[Nik_pelapoR] / [Jenis_kelamin_pelapoR]</td>
</tr>
<tr style="height: 19.2344px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;">17.</td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;">[Ttl_pelapoR]</td>
</tr>
<tr style="height: 19.2344px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.2344px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.2344px; vertical-align: top;">18.</td>
<td style="width: 30.5207%; text-align: left; height: 19.2344px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.30183%; text-align: center; height: 19.2344px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.2344px; vertical-align: top;">[Pekerjaan_pelapoR]</td>
</tr>
<tr style="height: 19.375px;" valign="top">
<td style="width: 4.33944%; text-align: center; height: 19.375px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 19.375px; vertical-align: top;">19.</td>
<td style="width: 30.5207%; text-align: left; height: 19.375px; vertical-align: top;">Alamat</td>
<td style="width: 1.30183%; text-align: center; height: 19.375px; vertical-align: top;">:</td>
<td style="width: 60.0289%; text-align: justify; height: 19.375px; vertical-align: top;">[Alamat_pelapoR]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya, atas perhatian dan terkabulnya diucapkan terima kasih.<br><br></p>
<table style="border-collapse: collapse; width: 100%; height: 415.985px;" border="0">
<tbody>
<tr style="height: 38.2344px;">
<td style="width: 35.0462%; text-align: center; height: 38.2344px;"> </td>
<td style="width: 30.0103%; height: 38.2344px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 38.2344px;"> </td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; text-align: center; height: 22.4688px;"> </td>
<td style="width: 30.0103%; height: 22.4688px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 22.4688px;">[Nama_desA], [TgL_surat]</td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; height: 22.4688px;"> </td>
<td style="width: 30.0103%; height: 22.4688px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 22.4688px;">[Sebutan_kepala_desA] [Nama_desA]</td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; height: 22.4688px;"> </td>
<td style="width: 30.0103%; height: 22.4688px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 22.4688px;"> </td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; height: 22.4688px;"> </td>
<td style="width: 30.0103%; height: 22.4688px;"> </td>
<td style="width: 35.0462%; text-align: left; height: 22.4688px;"> </td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; height: 22.4688px;"> </td>
<td style="width: 30.0103%; height: 22.4688px;"> </td>
<td style="width: 35.0462%; text-align: left; height: 22.4688px;"> </td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; height: 22.4688px;"> </td>
<td style="width: 30.0103%; text-align: center; height: 22.4688px;"> </td>
<td style="width: 35.0462%; height: 22.4688px; text-align: center;"><strong>Nama_pamonG</strong></td>
</tr>
<tr style="height: 22.4688px;">
<td style="width: 35.0462%; height: 22.4688px;"> </td>
<td style="width: 30.0103%; text-align: center; height: 22.4688px;"> </td>
<td style="width: 35.0462%; height: 22.4688px; text-align: center;">NIP : [Nip_kepala_camaT]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 35.0462%; height: 18px;"> </td>
<td style="width: 30.0103%; text-align: center; height: 18px;"> </td>
<td style="width: 35.0462%; text-align: center; height: 18px;"> </td>
</tr>
<tr style="height: 92px;">
<td style="width: 35.0462%; height: 92px;"> </td>
<td style="width: 30.0103%; text-align: center; height: 92px;">[qr_code]</td>
<td style="width: 35.0462%; text-align: center; height: 92px;"> </td>
</tr>
</tbody>
</table>
<div style="text-align: center;"> </div>