
                <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;">      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: 270px;" border="0" cellspacing="0" cellpadding="0">
                <tbody>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">1.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Nama</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;"><strong>[NAma]</strong></td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">2.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Tempat/tanggal lahir</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[TtL]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">3.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Umur</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[UsIa]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">4.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Warga negara</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[WArga_negara]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">5.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Agama</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[AgAma]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">6.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Jenis Kelamin</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[JeNis_kelamin]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">7.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Pekerjaan</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[Pekerjaan]</td>
                </tr>
                <tr style="height: 36px;">
                <td style="width: 5%; text-align: center; height: 36px;">8.</td>
                <td style="width: 33.773%; text-align: left; height: 36px;">Tempat tinggal</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 36px;">[AlamaT] [Sebutan_desa] [Nama_desa], Kecamatan [Nama_kecamatan], [Sebutan_kabupaten] [Nama_kabupaten]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">9.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Surat bukti diri</td>
                <td style="width: 1.22703%; text-align: left;"> </td>
                <td style="width: 60%; text-align: left; height: 18px;"> </td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;"> </td>
                <td style="width: 33.773%; text-align: left; height: 18px;">KTK</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[Nik]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;"> </td>
                <td style="width: 33.773%; text-align: left; height: 18px;">KK</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[No_kk]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">11.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Keterangan</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">Mohon keterangan yang akan dipergunakan untuk [Form_keterangan].</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">12.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Berlaku</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[mulai_berlaku] s/d [berlaku_sampai]</td>
                </tr>
                <tr style="height: 18px;">
                <td style="width: 5%; text-align: center; height: 18px;">13.</td>
                <td style="width: 33.773%; text-align: left; height: 18px;">Golongan Darah</td>
                <td style="width: 1.22703%; text-align: center;">:</td>
                <td style="width: 60%; text-align: left; height: 18px;">[GOl_darah]</td>
                </tr>
                </tbody>
                </table>
                <p style="text-align: justify;">             Demikian surat ini dibuat, untuk 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;">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>
            