<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]</p>
<p style="margin: 0; text-align: center;"> </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: 90px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<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;">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>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[TtL]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">3.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">NIK</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[NiK]</td>
</tr>
<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;">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>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">5.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Nomor Induk Siswa/Mahasiswa</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[Form_nomor_induk_siswamahasiswA]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">6.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Jurusan/Fakultas/Prodi</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[Form_jurusanfakultasprodI]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">7.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Sekolah/Perguruan Tinggi</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[Form_sekolahperguruan_tinggI]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">8.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Kelas/Semester</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[Form_kelassemesteR]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">9.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[AgamA]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">10.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[PekerjaaN]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.90545%; text-align: left; vertical-align: top;">11.</td>
<td style="width: 30.5242%; text-align: left; vertical-align: top;">Alamat</td>
<td style="width: 1.2333%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; vertical-align: top;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten], [Nama_provinsI]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Adalah benar penduduk yang berdomisili di [AlamaT], [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten], [Nama_provinsI], dan merupakan <strong>Anak </strong>dari:</p>
<table style="border-collapse: collapse; width: 100%; height: 310px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 18px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Nama Ayah</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; height: 18px; text-align: justify; vertical-align: top;">[Nama_ayaH]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 18px; text-align: left; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; height: 18px; text-align: justify; vertical-align: top;">[Ttl_ayaH]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 18px; text-align: left; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">NIK</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; height: 18px; text-align: justify; vertical-align: top;">[Nik_ayaH]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 18px; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; text-align: justify; height: 18px; vertical-align: top;">[Jenis_kelamin_ayaH]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 18px; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Agama</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 59.1624%; text-align: justify; height: 18px; vertical-align: top;">[Agama_ayaH]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 18px; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; text-align: justify; height: 18px; vertical-align: top;">[Pekerjaan_ayaH]</td>
</tr>
<tr style="height: 36px;">
<td style="width: 4.33944%; text-align: center; height: 36px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 36px; text-align: left; vertical-align: top;"><br><br></td>
<td style="width: 31.0993%; text-align: left; height: 36px; vertical-align: top;">Alamat<br><br></td>
<td style="width: 1.44509%; text-align: center; height: 36px; vertical-align: top;">:<br><br></td>
<td style="width: 59.1624%; height: 36px; text-align: justify; vertical-align: top;">[Alamat_ayaH] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten], [Nama_provinsI]</td>
</tr>
<tr>
<td style="width: 4.33944%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; vertical-align: top;">Penghasilan</td>
<td style="width: 1.44509%; text-align: center; vertical-align: top;">:</td>
<td style="width: 59.1624%; text-align: justify; vertical-align: top;">[Form_penghasilan_ayaH] <em>([Terbilang][[Form_penghasilan_ayaH]])</em></td>
</tr>
<tr style="height: 18px;">
<td style="text-align: center; width: 99.9518%; height: 18px; vertical-align: top;" colspan="5"> </td>
</tr>
<tr style="height: 22px;">
<td style="width: 4.33944%; text-align: center; height: 22px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 18px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Nama Ibu</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; height: 18px; text-align: justify; vertical-align: top;">[Nama_ibU]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 18px; text-align: left; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; height: 18px; text-align: justify; vertical-align: top;">[Ttl_ibU]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 18px; text-align: left; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">NIK</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; height: 18px; text-align: justify; vertical-align: top;">[Nik_ibU]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 18px; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; text-align: justify; height: 18px; vertical-align: top;">[Jenis_kelamin_ibU]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 18px; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Agama</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 59.1624%; text-align: justify; height: 18px; vertical-align: top;">[Agama_ibU]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.33944%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; height: 18px; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.44509%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 59.1624%; text-align: justify; height: 18px; vertical-align: top;">[Pekerjaan_ibU]</td>
</tr>
<tr style="height: 36px;">
<td style="width: 4.33944%; text-align: center; height: 36px; vertical-align: top;"> </td>
<td style="width: 3.9055%; height: 36px; text-align: left; vertical-align: top;"><br><br></td>
<td style="width: 31.0993%; text-align: left; height: 36px; vertical-align: top;">Alamat<br><br></td>
<td style="width: 1.44509%; text-align: center; height: 36px; vertical-align: top;">:<br><br></td>
<td style="width: 59.1624%; height: 36px; text-align: justify; vertical-align: top;">[Alamat_ibU] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten], [Nama_provinsI]</td>
</tr>
<tr>
<td style="width: 4.33944%; text-align: center; vertical-align: top;"> </td>
<td style="width: 3.9055%; text-align: left; vertical-align: top;"> </td>
<td style="width: 31.0993%; text-align: left; vertical-align: top;">Penghasilan</td>
<td style="width: 1.44509%; text-align: center; vertical-align: top;">:</td>
<td style="width: 59.1624%; text-align: justify; vertical-align: top;">[Form_penghasilan_ibU] <em>([Terbilang][[Form_penghasilan_ibU]])</em></td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Dengan penghasilan rata-rata <strong>Orang Tua [HitunG][[Form_penghasilan_ayaH]+[Form_penghasilan_ibU]] <em>([Terbilang][[HitunG][[Form_penghasilan_ayaH]+[Form_penghasilan_ibU]]])</em> </strong><strong> </strong>setiap bulannya.</p>
<p style="text-align: justify; text-indent: 30px;">Demikian Surat Keterangan Penghasilan Orangtua ini dibuat dengan sebenarnya agar dapat dipergunakan sebagaimana mestinya.</p>
<p> </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 style="text-align: center;"><br>[qr_code]</div>