Rujuk

lampiran 24 KMA No.  477        Tahun 2004

                                                                                                                                    - Pasal 5 ayat (2) - 

Model R-1

KANTOR DESA/KELURAHAN                  :  ....................................................................

KECAMATAN                                             :  ....................................................................

KABUPATEN/KOTA                                   :  ....................................................................

SURAT KETERANGAN UNTUK  RUJUK

Nomor : ....................................................

Yang bertanda tangan di bawah ini menerangkan dengan sesungguhnya bahwa :

I.       1.   Nama lengkap dan alias              : ..........................................................................................

2.                                                      Bin....................................................................................... :

3.   Tempat dan tanggal lahir             : ..........................................................................................

4.   Warganegara                               : ..........................................................................................

5.   Agama                                        : ..........................................................................................

6.   Pekerjaan                                    : ..........................................................................................

7.   Tempat tinggal                            : ..........................................................................................

akan merujuk :

II.     1.   Nama lengkap dan alias              : ..........................................................................................

2.   Binti                                            : ..........................................................................................

3.   Tempat dan tanggal lahir             : ..........................................................................................

4.   Warganegara                               : ..........................................................................................

5.   Agama                                        : ..........................................................................................

6.   Pekerjaan                                    : ..........................................................................................

7.   Tempat tinggal                            : ..........................................................................................

Demikianlah surat  keterangan ini dibuat dengan  mengingat sumpah jabatan dan dapat dipergunakan seperlunya.

                                                                     ............................................. , ................................ 20 …....

                                                                                                                                         

                                                                     Kepala Desa/Lurah  .............................................................

                                                                     ........................................................................................... ^*)

^*) nama lengkap