<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: 269.297px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;"><strong>[NaMa_ibu]</strong></td>
</tr>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">NIK / No. KTP</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;">[NiK_ibu]</td>
</tr>
<tr style="height: 25.8125px;">
<td style="width: 4.3222%; text-align: center; height: 25.8125px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 25.8125px; vertical-align: top;">3.</td>
<td style="width: 30.5174%; text-align: left; height: 25.8125px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.24427%; text-align: center; height: 25.8125px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 25.8125px; vertical-align: top;">[TtL_ibu]</td>
</tr>
<tr style="height: 21.8125px;">
<td style="width: 4.3222%; text-align: center; height: 21.8125px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 21.8125px; vertical-align: top;">4.</td>
<td style="width: 30.5174%; text-align: left; height: 21.8125px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.24427%; text-align: center; height: 21.8125px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 21.8125px; vertical-align: top;">[JeNis_kelamin_ibu]</td>
</tr>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">5.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">Agama</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;">[AgAma_ibu]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px; vertical-align: top;">6</td>
<td style="width: 30.5174%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.24427%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 18px; vertical-align: top;">[PeKerjaan]</td>
</tr>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">7.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;">[WArga_negara]</td>
</tr>
<tr style="height: 43.4844px;">
<td style="width: 4.3222%; text-align: center; height: 43.4844px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 43.4844px; vertical-align: top;">8.</td>
<td style="width: 30.5174%; text-align: left; height: 43.4844px; vertical-align: top;">Alamat / Tempat Tinggal</td>
<td style="width: 1.24427%; text-align: center; height: 43.4844px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 43.4844px; vertical-align: top;">[AlAmat_ibu] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Orang yang tersebut di atas adalah benar-benar warga kami yang bertempat tinggal di [AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten] dan tercatat dalam No. KK : [No_kK] dengan NIK [NiK_ibu] Kepala Keluarga : [Kepala_kK] dan menurut sepengetahuan kami memang benar berpenghasilan rata-rata [Form_jumlah_penghasilan_ibu] / Perbulan.<br><br></p>
<p>Surat Keterangan ini dibuat atas permintaan yang bersangkutan untuk keperluan anaknya untuk [Form_keperluaN] di<strong> [Form_nama_sekolaH]</strong><strong> </strong>atas nama :</p>
<table style="border-collapse: collapse; width: 100%; height: 269.297px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">1.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;"><strong>[NAma] </strong></td>
</tr>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">2.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">NIK / No. KTP</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;">[Nik]</td>
</tr>
<tr style="height: 25.8125px;">
<td style="width: 4.3222%; text-align: center; height: 25.8125px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 25.8125px; vertical-align: top;">3.</td>
<td style="width: 30.5174%; text-align: left; height: 25.8125px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.24427%; text-align: center; height: 25.8125px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 25.8125px; vertical-align: top;">[TtL]</td>
</tr>
<tr style="height: 21.8125px;">
<td style="width: 4.3222%; text-align: center; height: 21.8125px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 21.8125px; vertical-align: top;">4.</td>
<td style="width: 30.5174%; text-align: left; height: 21.8125px; vertical-align: top;">Jenis Kelamin</td>
<td style="width: 1.24427%; text-align: center; height: 21.8125px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 21.8125px; vertical-align: top;">[Jenis_kelamin]</td>
</tr>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">5.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">Agama</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;">[AgAma]</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;">6</td>
<td style="width: 30.5174%; text-align: left; vertical-align: top;">Status</td>
<td style="width: 1.24427%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; vertical-align: top;">[Status_kawiN]</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;">7.</td>
<td style="width: 30.5174%; text-align: left; vertical-align: top;">Pendidikan</td>
<td style="width: 1.24427%; text-align: center; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; vertical-align: top;">[Pendidikan_sedanG]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.3222%; text-align: center; height: 18px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 18px; vertical-align: top;">8.</td>
<td style="width: 30.5174%; text-align: left; height: 18px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.24427%; text-align: center; height: 18px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 18px; vertical-align: top;">[PeKerjaan]</td>
</tr>
<tr style="height: 19.75px;">
<td style="width: 4.3222%; text-align: center; height: 19.75px; vertical-align: top;"> </td>
<td style="width: 3.92927%; height: 19.75px; text-align: left; vertical-align: top;">9.</td>
<td style="width: 30.5174%; text-align: left; height: 19.75px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.24427%; text-align: center; height: 19.75px; vertical-align: top;">:</td>
<td style="width: 60.0524%; height: 19.75px; text-align: justify; vertical-align: top;">[WArga_negara]</td>
</tr>
<tr style="height: 43.4844px;">
<td style="width: 4.3222%; text-align: center; height: 43.4844px; vertical-align: top;"> </td>
<td style="width: 3.92927%; text-align: left; height: 43.4844px; vertical-align: top;">10.</td>
<td style="width: 30.5174%; text-align: left; height: 43.4844px; vertical-align: top;">Alamat / Tempat Tinggal</td>
<td style="width: 1.24427%; text-align: center; height: 43.4844px; vertical-align: top;">:</td>
<td style="width: 60.0524%; text-align: justify; height: 43.4844px; 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;">Demikian surat keterangan ini dibuat dengan sebenarnya, untuk dipergunakan sebagaimana mestinya.<br><br></p>
<table style="border-collapse: collapse; width: 100%; height: 144px;" border="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;"> </td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">[NaMa_desa], [TgL_surat]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;"> </td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">[Atas_namA]</td>
</tr>
<tr style="height: 72px;">
<td style="width: 35%; text-align: center; height: 72px;"> </td>
<td style="width: 30%; height: 72px;"><br><br><br><br></td>
<td style="width: 35%; height: 72px;"> </td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; text-align: center; height: 18px;"> </td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">[Nama_pamonG]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 35%; height: 18px;"> </td>
<td style="width: 30%; height: 18px;"> </td>
<td style="width: 35%; text-align: center; height: 18px;">[SEbutan_nip_desa] : [nip_pamong]</td>
</tr>
</tbody>
</table>
<div style="text-align: center;"><br>[qr_code]</div>