
                    <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: 82px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">1.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 36px;">
<td style="width: 4.31655%; text-align: center; height: 36px;"> </td>
<td style="width: 3.90545%; height: 36px; text-align: left;">2.<br /><br /></td>
<td style="width: 30.5242%; text-align: left; height: 36px;">Alamat / Tempat Tinggal<br /><br /></td>
<td style="width: 1.2333%; text-align: center; height: 36px;">:<br /><br /></td>
<td style="width: 60.0206%; height: 36px; text-align: justify;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">3.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[TtL]</td>
</tr>
<tr style="height: 10px;">
<td style="width: 4.31655%; text-align: center; height: 10px;"> </td>
<td style="width: 3.90545%; height: 10px; text-align: left;">4.</td>
<td style="width: 30.5242%; text-align: left; height: 10px;">Jenis Kelamin</td>
<td style="width: 1.2333%; text-align: center; height: 10px;">:</td>
<td style="width: 60.0206%; height: 10px; text-align: justify;">[Jenis_kelamin]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Dengan orang tua:</p>
<table style="border-collapse: collapse; width: 100%; height: 64px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">5.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Nama Ayah</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[NaMa_ayah]</td>
</tr>
<tr style="height: 10px;">
<td style="width: 4.31655%; text-align: center; height: 10px;"> </td>
<td style="width: 3.90545%; height: 10px; text-align: left;">6.</td>
<td style="width: 30.5242%; text-align: left; height: 10px;">NIK / No. KTP Ayah</td>
<td style="width: 1.2333%; text-align: center; height: 10px;">:</td>
<td style="width: 60.0206%; height: 10px; text-align: justify;">[Nik_ayah]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">7.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">Nama Ibu</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[NaMa_ibu]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90545%; height: 18px; text-align: left;">8.</td>
<td style="width: 30.5242%; text-align: left; height: 18px;">NIK / No. KTP Ibu</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Nik_ibu]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Adalah benar-benar warga [SeButan_desa] [NaMa_desa] dan belum pernah memiliki Akta Kelahiran.</p>
<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya untuk 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 style="text-align: center;"><br />[qr_code]</div>
                