<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 bahwa berdasarkan keterangan dari :</p>
<table style="border-collapse: collapse; width: 100%; height: 154px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 19.25px;">
<td style="width: 3.39157%; text-align: center; height: 19.25px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 19.25px; vertical-align: top;">1.</td>
<td style="width: 29.9075%; text-align: left; height: 19.25px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 19.25px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 19.25px; text-align: justify; vertical-align: top;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 19.25px;">
<td style="width: 3.39157%; text-align: center; height: 19.25px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 19.25px; vertical-align: top;">2.</td>
<td style="width: 29.9075%; text-align: left; height: 19.25px; vertical-align: top;">Bin</td>
<td style="width: 1.2333%; text-align: center; height: 19.25px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 19.25px; text-align: justify; vertical-align: top;">[NaMa_ayah]</td>
</tr>
<tr style="height: 19.25px;">
<td style="width: 3.39157%; text-align: center; height: 19.25px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 19.25px; vertical-align: top;">3.</td>
<td style="width: 29.9075%; text-align: left; height: 19.25px; vertical-align: top;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 19.25px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 19.25px; text-align: justify; vertical-align: top;">[TtL]</td>
</tr>
<tr style="height: 19.25px;">
<td style="width: 3.39157%; text-align: center; height: 19.25px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 19.25px; vertical-align: top;">4.</td>
<td style="width: 29.9075%; text-align: left; height: 19.25px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.2333%; text-align: center; height: 19.25px; vertical-align: top;">:</td>
<td style="width: 62.4872%; text-align: justify; height: 19.25px; vertical-align: top;">[WArga_negara]</td>
</tr>
<tr style="height: 19.25px;">
<td style="width: 3.39157%; text-align: center; height: 19.25px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 19.25px; vertical-align: top;">5.</td>
<td style="width: 29.9075%; text-align: left; height: 19.25px; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; height: 19.25px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 19.25px; text-align: justify; vertical-align: top;">[AgAma]</td>
</tr>
<tr style="height: 19.25px;">
<td style="width: 3.39157%; text-align: center; height: 19.25px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 19.25px; vertical-align: top;">6.</td>
<td style="width: 29.9075%; text-align: left; height: 19.25px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 19.25px; vertical-align: top;">:</td>
<td style="width: 62.4872%; text-align: justify; height: 19.25px; vertical-align: top;">[PeKerjaan]</td>
</tr>
<tr style="height: 38.5px;">
<td style="width: 3.39157%; text-align: center; height: 38.5px; vertical-align: top;"> </td>
<td style="width: 2.98047%; text-align: center; height: 38.5px; vertical-align: top;">7.</td>
<td style="width: 29.9075%; text-align: left; height: 38.5px; vertical-align: top;">Alamat / Tempat Tinggal</td>
<td style="width: 1.2333%; text-align: center; height: 38.5px; vertical-align: top;">:</td>
<td style="width: 62.4872%; text-align: justify; height: 38.5px; 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;">Telah rujuk/cerai *) dengan :<strong><br></strong></p>
<table style="border-collapse: collapse; width: 100%; height: 162.963px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 23.275px;">
<td style="width: 3.39157%; text-align: center; height: 23.275px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.275px; vertical-align: top;">8.</td>
<td style="width: 30.0103%; height: 23.275px; vertical-align: top;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 23.275px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.275px; vertical-align: top;"><strong>[NAma_pasangan]</strong></td>
</tr>
<tr style="height: 23.275px;">
<td style="width: 3.39157%; text-align: center; height: 23.275px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.275px; vertical-align: top;">9.</td>
<td style="width: 30.0103%; height: 23.275px; vertical-align: top;">Binti</td>
<td style="width: 1.2333%; text-align: center; height: 23.275px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.275px; vertical-align: top;">[FoRm_nama_ayah]</td>
</tr>
<tr style="height: 23.275px;">
<td style="width: 3.39157%; text-align: center; height: 23.275px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.275px; vertical-align: top;">10.</td>
<td style="width: 30.0103%; height: 23.275px; vertical-align: top;">Tempat dan Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 23.275px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.275px; vertical-align: top;">[TeMpatlahir_pasangan], [Tanggallahir_pasangaN]</td>
</tr>
<tr style="height: 23.275px;">
<td style="width: 3.39157%; text-align: center; height: 23.275px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.275px; vertical-align: top;">11.</td>
<td style="width: 30.0103%; height: 23.275px; vertical-align: top;">Kewarganegaraan</td>
<td style="width: 1.2333%; text-align: center; height: 23.275px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.275px; vertical-align: top;">[WArga_negara_pasangan]</td>
</tr>
<tr style="height: 23.275px;">
<td style="width: 3.39157%; text-align: center; height: 23.275px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.275px; vertical-align: top;">12.</td>
<td style="width: 30.0103%; height: 23.275px; vertical-align: top;">Agama</td>
<td style="width: 1.2333%; text-align: center; height: 23.275px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.275px; vertical-align: top;">[AgAma_pasangan]</td>
</tr>
<tr style="height: 23.275px;">
<td style="width: 3.39157%; text-align: center; height: 23.275px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.275px; vertical-align: top;">13.</td>
<td style="width: 30.0103%; height: 23.275px; vertical-align: top;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 23.275px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.275px; vertical-align: top;">[PeKerjaan_pasangan]</td>
</tr>
<tr style="height: 23.3125px;">
<td style="width: 3.39157%; text-align: center; height: 23.3125px; vertical-align: top;"> </td>
<td style="width: 2.8777%; text-align: center; height: 23.3125px; vertical-align: top;">14.</td>
<td style="width: 30.0103%; height: 23.3125px; vertical-align: top;">Alamat</td>
<td style="width: 1.2333%; text-align: center; height: 23.3125px; vertical-align: top;">:</td>
<td style="width: 62.4872%; height: 23.3125px; vertical-align: top;">[AlAmat_pasangan] </td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya, untuk dipergunakan sebagaimana mestinya.</p>
<p style="text-align: justify; text-indent: 30px;"> </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;"> </div>