PEMERINTAH
KABUPATEN........................
KECAMATAN..............................
DESA .................................
Alamat
; Jalan .......................................................................................
Kode Pos...........................
SURAT KETERANGAN PINDAH
Nomor : 13/ IV/ 2014
1.
N a m a : ..................................
2.
Jenis kelamin : .........................................
3.
Tempat / tgl lahir :
.........................., 12 Juli 1965
4.
Kewarganegaraan : WNI
5.
A g a m a : .................................
6.
Pekerjaan : ................................
7.
Status Perkawinan : .......................
8.
Pendidikan : ............................................
9.
No .tgl KTP : ............................................
10. Alamat asal : ................................................................................................................
11. Pindah ke : Desa : ..............................................................................
Kecamatan
: .............................................................
Kabupaten : ............................................................
Propinsi : ........................................................................
Pada tanggal : 23 - 04 - 2014
12. Alasan Pindah : Mengikuti .................................................
13. Pengikut : ..........................Orang
No
|
Nama
|
Kelamin
|
Umur
|
Status
Perkawinan
|
Pendi dikan
|
Nomor NIK
|
Ket
|
|
L
|
P
|
|||||||
1.
2.
|
......................
......................
|
-
-
|
-
-
|
........
.........
|
..................
....................
|
SLTP
SLTA
|
||
....................................., 23-04-2014
Kepala Desa .............................
.........................................
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