N4

                                                                      Lampiran 10 PMA No. 2 Tahun 1990

                                                                                           Pasal 8 ayat (1) huruf C

                                                                                                                                                         

Model N4

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

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

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

SURAT KETERANGAN  TENTANG  ORANG TUA

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

Yang bertanda di bawah ini menerangkan dengan sesungguhnya bahwa :

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

2. Tempat dan tanggal lahir                           :  .............................................................................

3. Warga Negara                                           :  .............................................................................

4. Agama                                                      :   .............................................................................

5. Pekerjaan                                                  :   .............................................................................

6. Tempat tinggal                                          :   .............................................................................

                                                                            

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

2. Tempat dan tanggal lahir                           :   .............................................................................

3. Warga Negara                                           :   .............................................................................

4. Agama                                                      :   .............................................................................

5. Pekerjaan                                                  :   .............................................................................

6. Tempat tinggal                                          :   .............................................................................

                                                                                    

Adalah benar ayah kandung dan ibu kandung dari seorang :

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

2. Tempat dan tanggal lahir                           :   .............................................................................

3. Warga Negara                                           :   .............................................................................

4. Jenis Kelamin                                           :   .............................................................................

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

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

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

                                                                            

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

		Kediri, ..................................
*) nama terang		Kepala Desa/Lurah ...............

                                                                                                                                               .......................................................

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