<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>
<table style="border-collapse: collapse; width: 100%; height: 156.771px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 22.3958px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Hari</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.3958px; text-align: justify; vertical-align: top;">[Hari_kelahiraN]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 22.3958px; vertical-align: top;">2.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Tanggal</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.3958px; vertical-align: top;">[Tanggal_kelahiraN]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 22.3958px; text-align: left; vertical-align: top;">3.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Pukul</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.3958px; text-align: justify; vertical-align: top;">[Jam_kelahiraN]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 22.3958px; text-align: left; vertical-align: top;">4.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Tempat</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.3958px; text-align: justify; vertical-align: top;">[Tempat_dilahirkanN]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 22.3958px; vertical-align: top;">5.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Telah lahir seorang anak</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.3958px; vertical-align: top;">[NAma]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Dari seorang ibu:</p>
<table style="border-collapse: collapse; width: 100%; height: 63px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 22px;">
<td style="width: 4.3222%; text-align: center; height: 22px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 22px; text-align: left; vertical-align: top;">6.</td>
<td style="width: 30.5174%; text-align: left; height: 22px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.24427%; text-align: center; height: 22px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 22px; text-align: justify; vertical-align: top;"><strong>[NAma_ibu]</strong></td>
</tr>
<tr style="height: 19px;">
<td style="width: 4.3222%; text-align: center; height: 19px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 19px; vertical-align: top;">7.</td>
<td style="width: 30.5174%; text-align: left; height: 19px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.24427%; text-align: center; height: 19px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 19px; vertical-align: top;">[Nik_ibU]</td>
</tr>
<tr style="height: 22px;">
<td style="width: 4.3222%; text-align: center; height: 22px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 22px; text-align: left; vertical-align: top;">8.</td>
<td style="width: 30.5174%; text-align: left; height: 22px; vertical-align: top;">Umur</td>
<td style="width: 1.24427%; text-align: center; height: 22px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 22px; text-align: justify; vertical-align: top;">[Usia_ibU]</td>
</tr>
<tr>
<td style="width: 4.3222%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; vertical-align: top;">9.</td>
<td style="width: 30.5174%; text-align: left; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.24427%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; vertical-align: top;">[Pekerjaan_ibU]</td>
</tr>
<tr>
<td style="width: 4.3222%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; vertical-align: top;">10.</td>
<td style="width: 30.5174%; text-align: left; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.24427%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; vertical-align: top;">[Alamat_ibU]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Istri dari:</p>
<table style="border-collapse: collapse; width: 100%; height: 63px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 22px;">
<td style="width: 4.3222%; text-align: center; height: 22px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 22px; text-align: left; vertical-align: top;">11.</td>
<td style="width: 30.5174%; text-align: left; height: 22px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.24427%; text-align: center; height: 22px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 22px; text-align: justify; vertical-align: top;"><strong>[NAma_ayah]</strong></td>
</tr>
<tr style="height: 19px;">
<td style="width: 4.3222%; text-align: center; height: 19px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 19px; vertical-align: top;">12.</td>
<td style="width: 30.5174%; text-align: left; height: 19px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.24427%; text-align: center; height: 19px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 19px; vertical-align: top;">[Nik_ayaH]</td>
</tr>
<tr style="height: 22px;">
<td style="width: 4.3222%; text-align: center; height: 22px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 22px; text-align: left; vertical-align: top;">13.</td>
<td style="width: 30.5174%; text-align: left; height: 22px; vertical-align: top;">Umur</td>
<td style="width: 1.24427%; text-align: center; height: 22px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 22px; text-align: justify; vertical-align: top;">[Usia_ayaH]</td>
</tr>
<tr>
<td style="width: 4.3222%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; vertical-align: top;">14.</td>
<td style="width: 30.5174%; text-align: left; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.24427%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; vertical-align: top;">[Pekerjaan_ayaH]</td>
</tr>
<tr>
<td style="width: 4.3222%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; vertical-align: top;">15.</td>
<td style="width: 30.5174%; text-align: left; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.24427%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; vertical-align: top;">[Alamat_ayaH]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Surat keterangan ini dibuat berdasarkan keterangan pelapor:</p>
<table style="border-collapse: collapse; width: 100%; height: 134.375px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 22.3958px; text-align: left; vertical-align: top;">16.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.3958px; text-align: justify; vertical-align: top;"><strong>[NAma_pelapor]</strong></td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 22.3958px; vertical-align: top;">17.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">NIK</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.3958px; vertical-align: top;">[Nik_pelapoR]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; height: 22.3958px; text-align: left; vertical-align: top;">18.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Umur</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.3958px; text-align: justify; vertical-align: top;">[Usia_pelapoR]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 22.3958px; vertical-align: top;">19.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.3958px; vertical-align: top;">[Pekerjaan_pelapoR]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 22.3958px; vertical-align: top;">20.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Alamat / Tempat Tinggal</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.3958px; vertical-align: top;">[Alamat_pelapoR]</td>
</tr>
<tr style="height: 22.3958px;">
<td style="width: 4.31655%; text-align: center; height: 22.3958px; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; height: 22.3958px; vertical-align: top;">21.</td>
<td style="width: 30.5242%; text-align: left; height: 22.3958px; vertical-align: top;">Hubungan pelapor dengan bayi</td>
<td style="width: 1.2333%; text-align: center; height: 22.3958px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.3958px; vertical-align: top;">[Form_hubungan_pelapor_dengan_bayI]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya agar dapat dipergunakan sebagaimana mestinya.<br><br></p>
<table style="border-collapse: collapse; width: 100%;" border="0">
<tbody>
<tr>
<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>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Atas_namA]</td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"><br><br><br><br></td>
<td style="width: 35%;"> </td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Nama_pamonG]</td>
</tr>
<tr>
<td style="width: 35%;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[SEbutan_nip_desa] : [nip_pamong]</td>
</tr>
</tbody>
</table>
<div> </div>
<div> </div>
<table style="border-collapse: collapse; width: 99.9875%; height: 50.5832px;" border="0">
<tbody>
<tr style="height: 10.3958;">
<td style="width: 8.50757%;">Perihal :</td>
<td style="text-align: left; width: 40.6481%;">Permohonan Penyelesaian</td>
<td style="width: 4.91468%;"> </td>
<td style="text-align: left; width: 45.9409%;"><strong>Kepada</strong></td>
</tr>
<tr style="height: 10.3958;">
<td style="width: 8.50757%;"> </td>
<td style="text-align: left; width: 40.6481%;">Akta Kelahiran</td>
<td style="width: 4.91468%;"><strong>Yth,</strong></td>
<td style="text-align: left; width: 45.9409%;"><strong>Kepala Dinas Kependudukan dan Pencatatan</strong></td>
</tr>
<tr style="height: 10.3958;">
<td style="width: 8.50757%;"> </td>
<td style="text-align: left; width: 40.6481%;"> </td>
<td style="width: 4.91468%;"> </td>
<td style="text-align: left; width: 45.9409%;"><strong>Sipil [Sebutan_kabupateN] [Nama_kabupateN]</strong></td>
</tr>
<tr style="height: 10.3958;">
<td style="width: 8.50757%;"> </td>
<td style="text-align: left; width: 40.6481%;"> </td>
<td style="width: 4.91468%;"> </td>
<td style="text-align: left; width: 45.9409%;"><strong>Di [Nama_kabupateN]</strong></td>
</tr>
</tbody>
</table>
<div style="text-align: justify;">Yang bertanda tangan di bawah ini :</div>
<table style="border-collapse: collapse; width: 99.9875%; height: 134.375px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 14.3958px;">
<td style="width: 33.274%; text-align: left; height: 14.3958px; vertical-align: top;">NIK</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.3192%; height: 14.3958px; text-align: justify; vertical-align: top;">[Nik_pelapoR]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.274%; text-align: left; height: 14.3958px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.3192%; text-align: justify; height: 14.3958px; vertical-align: top;"><strong>[NAma_pelapor]</strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.274%; text-align: left; height: 14.3958px; vertical-align: top;">Tempat tanggal lahir / umur</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.3192%; height: 14.3958px; text-align: justify; vertical-align: top;">[Tempat_tgl_lahir_pelapoR] / [Usia_pelapoR]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.274%; text-align: left; height: 14.3958px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.3192%; text-align: justify; height: 14.3958px; vertical-align: top;">[Pekerjaan_pelapoR]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.274%; text-align: left; height: 14.3958px; vertical-align: top;">Alamat / Tempat Tinggal</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.3192%; text-align: justify; height: 14.3958px; vertical-align: top;">[Alamat_pelapoR]</td>
</tr>
</tbody>
</table>
<div style="text-align: left;"><strong>Mohon dicatatkan kelahiran dalam register Akta Kelahiran dan diterbitkan kutipan Akta Kelahiran :</strong></div>
<table style="border-collapse: collapse; width: 99.9875%; height: 77.1875px; border: 1px solid rgb(0, 0, 0);" border="1"><colgroup> <col style="width: 3.87567%;"> <col style="width: 24.861%;"> <col style="width: 21.2689%;"> <col style="width: 16.637%;"> <col style="width: 16.637%;"> <col style="width: 16.637%;"> </colgroup>
<tbody>
<tr style="height: 14.3958px;">
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>No</strong></td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>Nama / Jenis Kelamin</strong></td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>Tempat Lahir</strong></td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>Tanggal Lahir</strong></td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>Anak Ke</strong></td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>No dan Tanggal Pendaftaran</strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);">1.</td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"><strong>[NAma] </strong>/ [Jenis_kelamiN]</td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);">[Tempat_dilahirkanN]</td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);">[Tanggal_kelahiraN]</td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);">[Kelahiran_anaK]</td>
<td style="height: 14.3958px; border-color: rgb(0, 0, 0);"> </td>
</tr>
</tbody>
</table>
<br>
<table style="border-collapse: collapse; width: 99.9875%; height: 134.375px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td style="width: 33.1795%; text-align: left; vertical-align: top;"><strong>Dari seorang ibu :</strong></td>
<td style="width: 1.41793%; text-align: center; vertical-align: top;"> </td>
<td style="width: 65.4137%; text-align: justify; vertical-align: top;"><strong> </strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;"><strong>[NAma_ibu]</strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Nik_ibU]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Tempat dan tanggal lahir / Umur</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;">[Tempat_tgl_lahir_ibU] / [Usia_ibU]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[WArga_negara_ibu]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Pekerjaan_ibU]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Alamat_ibU]</td>
</tr>
</tbody>
</table>
<table style="border-collapse: collapse; width: 99.9875%; height: 111.979px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td style="width: 33.1795%; text-align: left; vertical-align: top;"><strong>Istri dari :</strong></td>
<td style="width: 1.41793%; text-align: center; vertical-align: top;"> </td>
<td style="width: 65.4137%; text-align: justify; vertical-align: top;"><strong> </strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;"><strong>[NAma_ayah]</strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Nik_ayaH]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Tempat dan tanggal lahir / Umur</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;">[Tempat_tgl_lahir_ayaH] / [Usia_ayaH]</td>
</tr>
<tr>
<td style="width: 33.1795%; text-align: left; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.41793%; text-align: center; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; vertical-align: top;">[Warga_negara_ayaH]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Pekerjaan_ayaH]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Alamat_ayaH]</td>
</tr>
</tbody>
</table>
<table style="border-collapse: collapse; width: 99.9875%; height: 134.375px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td style="width: 33.1795%; text-align: left; vertical-align: top;"><strong>Saksi 1 :</strong></td>
<td style="width: 1.41793%; text-align: center; vertical-align: top;"> </td>
<td style="width: 65.4137%; text-align: justify; vertical-align: top;"><strong> </strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;"><strong>[Nama_saksi_I]</strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Nik_saksi_I]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Tempat dan tanggal lahir / Umur</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;">[Tempat_tgl_lahir_saksi_I] / [Usia_saksi_I]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[WArga_negara_saksi_i]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Pekerjaan_saksi_I]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Alamat_saksi_I]</td>
</tr>
</tbody>
</table>
<table style="border-collapse: collapse; width: 99.9875%; height: 134.375px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr>
<td style="width: 33.1795%; text-align: left; vertical-align: top;"><strong>Saksi 2 :</strong></td>
<td style="width: 1.41793%; text-align: center; vertical-align: top;"> </td>
<td style="width: 65.4137%; text-align: justify; vertical-align: top;"><strong> </strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;"><strong>[NAma_saksi_ii]</strong></td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">NIK / No KTP</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Nik_saksi_iI]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Tempat dan tanggal lahir / Umur</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; height: 14.3958px; text-align: justify; vertical-align: top;">[Tempat_tgl_lahir_saksi_iI] / [Usia_saksi_iI]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[WArga_negara_saksi_ii]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Pekerjaan_saksi_iI]</td>
</tr>
<tr style="height: 14.3958px;">
<td style="width: 33.1795%; text-align: left; height: 14.3958px; vertical-align: top;">Alamat/Tempat Tinggal</td>
<td style="width: 1.41793%; text-align: center; height: 14.3958px; vertical-align: top;">:</td>
<td style="width: 65.4137%; text-align: justify; height: 14.3958px; vertical-align: top;">[Alamat_saksi_iI]</td>
</tr>
</tbody>
</table>
<div style="text-align: center;"> </div>
<table style="width: 100%; height: 43.979px;">
<tbody>
<tr style="height: 8.3958px;">
<td style="width: 94.4397%; height: 8.3958px;"><span style="font-size: 10px;"><strong>Terlampir persyaratan sebagai berikut :</strong></span></td>
</tr>
<tr style="height: 8.3958px;">
<td>
<div style="font-size: 10px;">1. Surat keterangan kelahiran dari penolong atau dari Desa/Lurah</div>
<div style="font-size: 10px;">2. Fotocopy KTP dan kartu keluarga orang tua</div>
<div style="font-size: 10px;">3. Fotocopy Buku Nikah / akta perkawinan orang tua yang telah dilegalisir (bagi yang memiliki)</div>
<div style="font-size: 10px;">4. Fotocopy KTP 2 orang saksi yang masih berlaku</div>
<div style="font-size: 10px;">5. Fotocopy Ijazah / Raport (bagi yang memiliki)</div>
</td>
</tr>
</tbody>
</table>
<table style="border-collapse: collapse; width: 99.9875%; height: 99.5833px;"><colgroup> <col style="width: 32.8014%;"> <col style="width: 33.9357%;"> <col style="width: 33.274%;"> </colgroup>
<tbody>
<tr style="height: 22.3958px;">
<td style="height: 22.3958px;"> </td>
<td style="height: 22.3958px;"> </td>
<td style="text-align: center; height: 22.3958px;">[NaMa_desa], [TgL_surat]</td>
</tr>
<tr style="height: 10px;">
<td style="height: 54.7917px;" rowspan="2">
<table style="border-collapse: collapse; width: 100.415%; border: 1px solid rgb(0, 0, 0);" border="1"><colgroup> <col style="width: 33.6245%;"> <col style="width: 66.2547%;"> </colgroup>
<tbody>
<tr>
<td style="text-align: center; border-color: rgb(0, 0, 0);" rowspan="2"><strong>Verifikasi</strong></td>
<td style="text-align: left; border-color: rgb(0, 0, 0);"><strong>Kasi</strong></td>
</tr>
<tr>
<td style="text-align: left; border-color: rgb(0, 0, 0);"><strong>Kabid</strong></td>
</tr>
</tbody>
</table>
</td>
<td style="height: 54.7917px;" rowspan="2"> </td>
<td style="text-align: center; height: 10px;">Pelapor</td>
</tr>
<tr style="height: 44.7917px;">
<td style="height: 44.7917px;"> </td>
</tr>
<tr style="height: 22.3958px;">
<td style="height: 22.3958px;"> </td>
<td style="height: 22.3958px;"> </td>
<td style="text-align: center; height: 22.3958px;"><strong>[Nama_pelapoR]</strong></td>
</tr>
</tbody>
</table>
<div style="text-align: center;"> </div>