<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: 246.4px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; height: 22.4px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.4px; text-align: justify; vertical-align: top;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; text-align: left; height: 22.4px; vertical-align: top;">2.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">ID BDT</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.4px; vertical-align: top;">[Id_bdT]</td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; height: 22.4px; text-align: left; vertical-align: top;">3.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">No. KTP</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.4px; text-align: justify; vertical-align: top;">[Nik]</td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; height: 22.4px; text-align: left; vertical-align: top;">4.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.4px; text-align: justify; vertical-align: top;">[Ttl]</td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; height: 22.4px; text-align: left; vertical-align: top;">5.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; height: 22.4px; text-align: justify; vertical-align: top;">[Jenis_kelamin]</td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; text-align: left; height: 22.4px; vertical-align: top;">6.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.4px; vertical-align: top;">[WArga_negara]</td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; text-align: left; height: 22.4px; vertical-align: top;">7.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.4px; vertical-align: top;">[AgAma]</td>
</tr>
<tr style="height: 22.4px;">
<td style="width: 4.31655%; text-align: center; height: 22.4px; vertical-align: top;"> </td>
<td style="width: 3.90429%; text-align: left; height: 22.4px; vertical-align: top;">8.</td>
<td style="width: 30.5253%; text-align: left; height: 22.4px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 22.4px; vertical-align: top;">:</td>
<td style="width: 60.0206%; text-align: justify; height: 22.4px; vertical-align: top;">[PeKerjaan]</td>
</tr>
<tr style="height: 67.2px;">
<td style="width: 4.31655%; text-align: center; height: 67.2px; vertical-align: top;"> </td>
<td style="width: 3.90429%; height: 67.2px; text-align: left; vertical-align: top;">7.<br><br></td>
<td style="width: 30.5253%; text-align: left; height: 67.2px; vertical-align: top;">Alamat / Tempat Tinggal<br><br></td>
<td style="width: 1.2333%; text-align: center; height: 67.2px; vertical-align: top;">:<br><br></td>
<td style="width: 60.0206%; height: 67.2px; text-align: justify; vertical-align: top;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Bahwa yang tersebut namanya di atas, sepanjang pengetahuan dan penelitian kami hingga saat dikeluarkannya surat keterangan ini memang benar Keluarga yang KURANG MAMPU dan tidak memiliki pengahasilan tetap.<br><br></p>
<p style="text-indent: 30px; text-align: center;"><span style="text-decoration: underline;"><strong>DAFTAR TANGGUNGAN KELUARGA<br></strong></span></p>
<table style="border-collapse: collapse; width: 100%; height: 138px;" border="1">
<tbody>
<tr style="height: 12px;">
<td style="width: 6.37205%; text-align: center; height: 12px;"><span style="font-size: 10pt;"><strong>NO.</strong></span></td>
<td style="width: 20.8633%; text-align: center; height: 12px;"><span style="font-size: 10pt;"><strong>NIK</strong></span></td>
<td style="width: 19.63%; text-align: center; height: 12px;"><span style="font-size: 10pt;"><strong>NAMA</strong></span></td>
<td style="width: 13.4639%; text-align: center; height: 12px;"><span style="font-size: 10pt;"><strong>L / P</strong></span></td>
<td style="width: 24.7683%; text-align: center; height: 12px;"><span style="font-size: 10pt;"><strong>TEMPAT TANGGAL LAHIR</strong></span></td>
<td style="width: 14.7996%; text-align: center; height: 12px;"><span style="font-size: 10pt;"><strong>SHDK</strong></span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg1_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg1_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg1_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg1_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg1_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg1_hubungan_kk]</span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg2_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg2_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg2_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg2_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg2_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg2_hubungan_kk]</span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg3_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg3_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg3_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg3_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg3_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg3_hubungan_kk]</span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg4_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg4_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg4_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg4_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg4_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg4_hubungan_kk]</span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg5_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg5_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg5_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg5_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg5_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg5_hubungan_kk]</span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg6_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg6_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg6_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg6_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg6_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg6_hubungan_kk]</span></td>
</tr>
<tr style="height: 18px;">
<td style="width: 6.37205%; height: 18px; text-align: center;"><span style="font-size: 10pt;">[KLg7_no]</span></td>
<td style="width: 20.8633%; height: 18px;"><span style="font-size: 10pt;">[KLg7_nik]</span></td>
<td style="width: 19.63%; height: 18px;"><span style="font-size: 10pt;">[KLg7_nama]</span></td>
<td style="width: 13.4639%; height: 18px;"><span style="font-size: 10pt;">[KLg7_jenis_kelamin]</span></td>
<td style="width: 24.7683%; height: 18px;"><span style="font-size: 10pt;">[KLg7_ttl]</span></td>
<td style="width: 14.7996%; height: 18px;"><span style="font-size: 10pt;">[KLg7_hubungan_kk]</span></td>
</tr>
</tbody>
</table>
<p style="text-indent: 30px;">Surat Keterangan ini dibuat untuk keperluan : <span style="text-decoration: underline;"><strong>[Form_keperluaN]</strong></span></p>
<p style="text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya, untuk 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;">Pemegang Surat</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;">[NAma]</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>