{\rtf1{\fonttbl

{\f2 Arial Bold;}

{\f3 Arial;}
{\f4 Calibri;}
{\f1000000 Times New Roman;}
}{\colortbl;
\red0\green0\blue0;
\red0\green0\blue0;
\red0\green0\blue0;
}\viewkind1\viewscale100\margl0\margr0\margt0\margb0\deftab80\dntblnsbdb\expshrtn\
paperw12240\paperh20160\pard\sb0\sl-240{\bkmkstart Pg1}{\bkmkend Pg1}\par\pard\ql \
li4840\sb0\sl-276\slmult0 \par\pard\ql\li4840\sb0\sl-276\slmult0 \par\pard\ql\
li4840\sb0\sl-276\slmult0 \par\pard\ql\li4840\sb0\sl-276\slmult0 \par\pard\ql\
li4840\sb108\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\
fs24 SURAT PERNYATAAN \par\pard\ql \li1440\sb0\sl-276\slmult0 \par\pard\ql\li1440\
sb0\sl-276\slmult0 \par\pard\ql\li1440\sb112\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 \ul0\nosupersub\cf2\f3\fs24 Yang bertanda tangan di bawah ini :\par\
pard\sect\sectd\sbknone\cols2\colno1\colw4161\colsr160\colno2\colw7779\colsr160\
ql \li1440\sb214\sl-276\slmult0 \up0 \expndtw-3\charscalex100 nama\par\pard\qj \
li1440\ri523\sb38\sl-474\slmult0 \up0 \expndtw-3\charscalex100 tempat tanggal lahir
\up0 \expndtw-3\charscalex100 agama\par\pard\ql \li1440\sb167\sl-276\slmult0 \up0 \
expndtw-3\charscalex100 alamat\par\pard\qj \li1440\sb0\sl-476\slmult0 \par\pard\
qj \li1440\ri242\sb35\sl-476\slmult0 \up0 \expndtw-3\charscalex100 Nomor Kartu
Keluarga \line \up0 \expndtw-4\charscalex100 NIK\par\pard\column \ql \li20\sb214\
sl-276\slmult0 \up0 \expndtw-3\charscalex100 : \u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?..\par\pard\qj \li20\ri2130\sb37\sl-475\
slmult0\tx209 \up0 \expndtw-3\charscalex100 : \u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?.. \up0 \expndtw-3\charscalex100 : \
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?.. \up0
\expndtw-3\charscalex100 : \u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?.. \line\tab \up0 \expndtw-3\charscalex100 Depok,
Sleman, Yogyakarta\par\pard\qj \li20\ri2130\sb2\sl-476\slmult0 \up0 \expndtw-3\
charscalex100 : \u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?.. \line \up0 \expndtw-3\charscalex100 : \u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?.. \par\pard\sect\sectd\sbknone \qj
\li1440\ri1226\sb169\sl-270\slmult0 \up0 \expndtw0\charscalex102 Dengan ini
menyatakan dengan sesungguhnya bahwa saya belum pernah memiliki / \up0 \expndtw0\
charscalex104 mengurus Kartu Tanda Penduduk sebelumnya. Surat Pernyataan ini saya
gunakan \up0 \expndtw-3\charscalex100 untuk melengkapi persyaratan pembuatan Kartu
Tanda Penduduk baru. \par\pard\qj \li1440\ri1226\sb202\sl-280\slmult0 \up0 \
expndtw0\charscalex100 Demikian pernyataan ini saya buat dengan penuh kesadaran dan
apabila di kemudian \up0 \expndtw0\charscalex100 hari pernyataan ini tidak
benar, saya bersedia dituntut di muka pengadilan dan \up0 \expndtw-3\
charscalex100 menerima sanksi sesuai peraturan perundang - undangan yang
berlaku. \par\pard\ql \li7199\sb0\sl-276\slmult0 \par\pard\ql\li7199\sb268\sl-276\
slmult0 \up0 \expndtw-3\charscalex100 Depok, \u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?. \par\pard\ql \li7751\sb4\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 Hormat Saya, \par\pard\ql \li8336\sb0\sl-184\slmult0 \par\pard\ql\
li8336\sb16\sl-184\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf3\f4\
fs16 ttd \par\pard\ql \li8176\sb16\sl-184\slmult0 \up0 \expndtw-2\charscalex100
materai \par\pard\ql \li8249\sb16\sl-184\slmult0 \up0 \expndtw-2\charscalex100
6.000 \par\pard\ql \li5520\sb0\sl-276\slmult0 \par\pard\ql\li5520\sb0\sl-276\
slmult0 \par\pard\ql\li5520\sb0\sl-276\slmult0 \par\pard\ql\li5520\sb52\sl-276\
slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf2\f3\fs24 Mengetahui, \par\
pard\li3211\sb2\sl-276\slmult0\fi0\tx7978 \up0 \expndtw-4\charscalex100 Ketua RW\
tab \up0 \expndtw-4\charscalex100 Ketua RT\par\pard\li5425\sb0\sl-276\slmult0\par\
pard\li5425\sb0\sl-276\slmult0\par\pard\li5425\sb0\sl-276\slmult0\par\pard\li5425\
sb0\sl-276\slmult0\par\pard\li5425\sb1\sl-276\slmult0\fi1671 \up0 \expndtw-3\
charscalex100 \u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\u8230?\
u8230?\u8230?..\par\pard\li5425\sb276\sl-276\slmult0\fi0 \up0 \expndtw-3\
charscalex100 Kepala Dukuh

{\shp {\*\shpinst\shpleft7936\shptop9285\shpright8926\shpbottom10065\shpfhdr0\
shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz996\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 990}}{\sp{\sn geoBottom}{\sv 780}}
{\sp{\sn pVerticies}{\sv 8;4;(0,780);(990,780);(990,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv
16777215}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}
{\sv 1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft7935\shptop9285\shpright8925\shpbottom10065\shpfhdr0\
shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz1001\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{\sn
geoRight}{\sv 990}}{\sp{\sn geoBottom}{\sv 780}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,780);(990,780);(990,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 9449}}{\
sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocument}{\
sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft7935\shptop10065\shpright7935\shpbottom9285\shpfhdr0\
shpbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz1001\shplid2{\sp{\sn shapeType}
{\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}{\sp{\sn
lineWidth}{\sv 9449}}
}}\par\pard\sect\sectd\fs24}