STATEMENT LETTER

OF NOT RECEIVING SCHOLARSHIP

I declare that below

Name

Place/Date of Birth

Student No.

Univ./Institution

Major / Study Program

Semester

Status

Origin Address

Current Address

Mobile Phone No.

I declare that I am not receiving any form of scholarship in the year of 2016, either from the
centre or the local government, other private institutions (local or foreign), nor from other countries.
I understand that this is a legal obligation, should there be any counterfeit or misleading
information could result in penalties under the state law, and I shall be responsible to return back all
the scholarship that i have received.
I declare that all above information is given based on truth.

Samarinda,
Acknowledge,

2016

Appelant

Headmaster/Chancellor
Materai
Rp.6000