SURAT KETERANGAN ANAK DARI

                 PEMERINTAH KABUPATEN CIAMIS

                           KECAMATAN RANCAH

        KANTOR KEPALA DESA KIARAPAYUNG

                    Jalan Raya Rancah Sukadana No. 01

                          RANCAH, 46387

SURAT KETERANGAN

Nomor : 140/ 001 /  I / Ds-2015

 

Yang bertandatangan dibawah ini Kepala Desa Kiarapayung Kec. Rancah Kabupaten Ciamis menerangkan bahwa :

                        Nama Lengkap           :  ..................

Tempat/ Tgl. Lahir       :  Ciamis, 18 – 09 - 1970

Jenis Kelamin             :  Laki-Laki

Alamat Lengkap          :  Dusun Ciroyom RT. 003  RW. 010                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              

                                                              Desa Kiarapayung Kec. Rancah Ciamis

            Adalah anak dari  ............ dan .......................

Demikian Surat Keterangan ini dibuat dengan sebenarnya untuk menjadi bahan sebagaimana mestinya.

                                                                                   Kiarapayung, 06 Januari  2015

                                                                                    KEPALA DESA KIARAPAYUNG

                                                                                              

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