<div class="newpage" id="page1" style="width: 902px; height: 1486px; transform:

scale(0.679601); transform-origin: left top; display: block;">

<div class="text_layer" style="z-index:2"><div class="ie_fix">
&nbsp;
<div class="ff1" style="font-size:93px">
<span class="a" style="left:1482px;top:415px;word-spacing:2px">SURAT PERNYATAAN
SILSILAH</span></div>
<div class="ff1" style="font-size:80px">
<span class="a" style="left:266px;top:660px">Yang bertanda tangan dibawah ini :</span><span
class="a" style="left:266px;top:873px;word-spacing:-22px;letter-spacing:30px">1<span
class="l" style="margin-left:-30px">.<span class="w" style="width:36px"></span>N<span
class="l" style="margin-left:-30px">a<span class="l" style="margin-left:-30px">m<span
class="l" style="margin-left:-30px">a<span class="w" style="width:157px"></span>: <span
class="l" style="margin-left:-38px">(<span class="l" style="margin-left:-30px">i<span
class="l" style="margin-left:-31px">s<span class="l" style="margin-left:-30px">t<span
class="l" style="margin-left:-31px">r<span class="l" style="margin-left:-31px">i<span
class="l" style="margin-left:-30px">/<span class="l" style="margin-left:-31px">s<span
class="l" style="margin-left:-31px">u<span class="l" style="margin-left:-29px">a<span
class="l" style="margin-left:-30px">m<span class="l" style="margin-left:-31px">i <span
class="l" style="margin-left:-38px">d<span class="l" style="margin-left:-29px">i<span
class="l" style="margin-left:-31px">t<span class="l" style="margin-left:-31px">i<span
class="l" style="margin-left:-30px">n<span class="l" style="margin-left:-30px">g<span
class="l" style="margin-left:-30px">g<span class="l" style="margin-left:-30px">a<span
class="l" style="margin-left:-30px">l<span class="l" style="margin-left:-30px">k<span
class="l" style="margin-left:-30px">a<span class="l" style="margin-left:-29px">n<span
class="l" style="margin-left:-30px">)<span class="w" style="width:743px"></span>U<span
class="l" style="margin-left:-30px">m<span class="l" style="margin-left:-31px">u<span
class="l" style="margin-left:-30px">r<span class="w" style="width:77px"></span>:
</span></span></span></span></span></span></span></span></span></span></span></span>
</span></span></span></span></span></span></span></span></span></span></span></span>
</span></span></span></span></span></span></span></span></span><span class="a"
style="left:266px;top:1086px;word-spacing:-98px;letter-spacing:100px">2<span class="l"
style="margin-left:-100px">.<span class="l" style="margin-left:-34px">N<span class="l"
style="margin-left:-100px">a<span class="l" style="margin-left:-100px">m<span class="l"
style="margin-left:-100px">a<span class="w" style="width:87px"></span>: <span class="l"
style="margin-left:-102px">(<span class="l" style="margin-left:-100px">a<span class="l"
style="margin-left:-100px">n<span class="l" style="margin-left:-100px">a<span class="l"
style="margin-left:-100px">k<span class="l" style="margin-left:-100px">)<span class="w"
style="width:1343px"></span>U<span class="l" style="margin-left:-100px">m<span class="l"
style="margin-left:-101px">u<span class="l" style="margin-left:-100px">r<span
class="w7"></span>:
</span></span></span></span></span></span></span></span></span></span></span></span>
</span></span></span><span class="a" style="left:266px;top:1299px;word-spacing:-
75px;letter-spacing:76px">3<span class="l" style="margin-left:-76px">.<span
class="l10">N<span class="l" style="margin-left:-76px">a<span class="l" style="margin-left:-
76px">m<span class="l" style="margin-left:-76px">a<span class="w"
style="width:111px"></span>: <span class="l" style="margin-left:-77px">(<span class="l"
style="margin-left:-76px">a<span class="l" style="margin-left:-76px">n<span class="l"
style="margin-left:-76px">a<span class="l" style="margin-left:-76px">k<span class="l"
style="margin-left:-76px">/<span class="l" style="margin-left:-76px">d<span class="l"
style="margin-left:-76px">s<span class="l" style="margin-left:-77px">t<span class="l"
style="margin-left:-76px">)<span class="w" style="width:1239px"></span>U<span class="l"
style="margin-left:-76px">m<span class="l" style="margin-left:-77px">u<span class="l"
style="margin-left:-76px">r<span class="w" style="width:31px"></span>:
</span></span></span></span></span></span></span></span></span></span></span></span>
</span></span></span></span></span></span></span><span class="a"
style="left:531px;top:1512px;word-spacing:-3px">Kami tersebut di <span
class="w7"></span>atas sama-sama beralamat <span
class="w7"></span>di…………………………<span class="l6">……………………………
</span></span><span class="a" style="left:266px;top:1619px;letter-spacing:-
1px">……………………………………………..</span><span class="a"
style="left:266px;top:1832px">Dengan ini menyatakan bahwa susunan silsilah keluarga kami
adalah sebagai berikut :</span><span class="a" style="left:527px;top:2683px;word-
spacing:8px;letter-spacing:1px">Demikian surat pernyataan ini dibuat tanpa ada paksaan dari
pihak manapun juga. Apabila ternyata</span><span class="a"
style="left:266px;top:2790px;word-spacing:14px;letter-spacing:2px">per<span
class="l7">nyat<span class="l8">aan <span class="w9"></span>ini <span
class="w6"></span>tid<span class="l7">ak <span class="w10"></span>bena<span
class="l7">r, <span class="w9"></span>kam<span class="l6">i <span
class="w11"></span>ber<span class="l7">sed<span class="l6">ia <span
class="w9"></span>dit<span class="l7">unt<span class="l6">ut <span
class="w9"></span>ses<span class="l6">uai <span class="w7"></span>den<span
class="l6">gan <span class="w8"></span>ket<span class="l6">ent<span class="l7">uan <span
class="w9"></span>huku<span class="l7">m <span class="w11"></span>yan<span
class="l6">g <span class="w11"></span>ber<span class="l6">lak<span class="l6">u <span
class="w12"></span>tan<span
class="l6">pa</span></span></span></span></span></span></span></span></span></span></
span></span></span></span></span></span></span></span></span><span class="a"
style="left:266px;top:2896px">melibatkan Para Pejabat yang mengetahui di bawah
ini.</span><span class="a" style="left:796px;top:3215px;word-spacing:503px">&nbsp;<span
class="w" style="width:1509px"></span>Tempat, <span class="l" style="margin-left:-
502px">Tanggal <span class="l" style="margin-left:-503px">Bulan <span class="l"
style="margin-left:-502px">Tahun</span></span></span></span><span class="a"
style="left:2930px;top:3322px">Yang Menyatakan :</span></div>
<div class="ff1" style="font-size:74px">
<span class="a" style="left:266px;top:3533px">Saksi-saksi</span><span class="a"
style="left:266px;top:3638px;word-spacing:-7px;letter-spacing:7px">1<span class="l8">. <span
class="w" style="width:15px"></span>N<span class="l8">a<span class="l7">m<span
class="l7">a<span class="w" style="width:225px"></span>: <span class="l8">&lt;<span
class="l7">N<span class="l8">a<span class="l7">m<span class="l8">a <span
class="l8">S<span class="l8">a<span class="l7">k<span class="l8">s<span class="l7">i <span
class="l8">1<span class="l8">&gt;<span class="w" style="width:139px"></span>(<span
class="l7">.<span class="l8">.<span class="l8">.<span class="l8">.<span class="l7">.<span
class="l8">.<span class="l8">.<span class="l8">.<span class="l7">.<span class="l9">.<span
class="l7">.<span class="l8">.<span class="l7">.<span class="l9">.<span class="l7">.<span
class="l8">.<span class="l8">.<span class="l8">.<span class="l7">.<span class="l8">.<span
class="l8">.<span class="l8">.<span class="l7">.<span class="l8">.<span class="l8">.<span
class="l8">.<span class="l7">.<span class="l8">.<span class="l8">.<span class="l8">.<span
class="l7">.<span class="l9">.<span
class="l7">)</span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></div>
<div class="ff1" style="font-size:80px">
<span class="a" style="left:2564px;top:3633px;word-spacing:12px">1. <span
class="l12">&lt;Nama <span class="l12">Istri/suami&gt; <span class="w"
style="width:28px"></span>(………………)</span></span></span><span class="a"
style="left:370px;top:3739px;word-spacing:-24px;letter-spacing:22px">U<span class="l"
style="margin-left:-22px">m<span class="l" style="margin-left:-22px">u<span class="l"
style="margin-left:-22px">r<span class="w" style="width:197px"></span>: <span class="l"
style="margin-left:-20px">&lt;<span class="l" style="margin-left:-22px">U<span class="l"
style="margin-left:-22px">m<span class="l" style="margin-left:-23px">u<span class="l"
style="margin-left:-22px">r<span class="l" style="margin-left:-
22px">&gt;</span></span></span></span></span></span></span></span></span></span><sp
an class="a" style="left:370px;top:3846px;word-spacing:-9px;letter-spacing:41px">A<span
class="l" style="margin-left:-41px">l<span class="l" style="margin-left:-41px">a<span
class="l" style="margin-left:-41px">m<span class="l" style="margin-left:-42px">a<span
class="l" style="margin-left:-41px">t<span class="w" style="width:125px"></span>: <span
class="l" style="margin-left:-73px">&lt;<span class="l" style="margin-left:-41px">A<span
class="l" style="margin-left:-41px">l<span class="l" style="margin-left:-42px">a<span
class="l" style="margin-left:-41px">m<span class="l" style="margin-left:-42px">a<span
class="l" style="margin-left:-40px">t<span class="l" style="margin-left:-42px">&gt;<span
class="w" style="width:1321px"></span>2<span class="l" style="margin-left:-41px">. <span
class="l" style="margin-left:-73px">&lt;<span class="l" style="margin-left:-41px">N<span
class="l" style="margin-left:-41px">a<span class="l" style="margin-left:-41px">m<span
class="l" style="margin-left:-42px">a <span class="l" style="margin-left:-72px">A<span
class="l" style="margin-left:-41px">n<span class="l" style="margin-left:-41px">a<span
class="l" style="margin-left:-40px">k <span class="l" style="margin-left:-73px">1<span
class="l" style="margin-left:-41px">&gt; <span class="w" style="width:82px"></span>(<span
class="l" style="margin-left:-42px">…<span class="l" style="margin-left:-41px">…<span
class="l" style="margin-left:-42px">…<span class="l" style="margin-left:-41px">…<span
class="l" style="margin-left:-42px">…<span class="l" style="margin-left:-41px">…<span
class="l" style="margin-left:-42px">.<span class="l" style="margin-left:-41px">.<span class="l"
style="margin-left:-
41px">)</span></span></span></span></span></span></span></span></span></span></span>
</span></span></span></span></span></span></span></span></span></span></span></span>
</span></span></span></span></span></span></span></span></span></span></span></span>
</div>
<div class="ff1" style="font-size:74px">
<span class="a" style="left:266px;top:4170px;word-spacing:-7px;letter-spacing:7px">2<span
class="l8">. <span class="w" style="width:15px"></span>N<span class="l8">a<span
class="l7">m<span class="l7">a<span class="w" style="width:225px"></span>: <span
class="l8">&lt;<span class="l7">N<span class="l8">a<span class="l7">m<span class="l8">a
<span class="l8">S<span class="l8">a<span class="l7">k<span class="l8">s<span class="l7">i
<span class="l8">2<span class="l8">&gt;<span class="w" style="width:139px"></span>(<span
class="l7">.<span class="l8">.<span class="l8">.<span class="l8">.<span class="l7">.<span
class="l8">.<span class="l8">.<span class="l8">.<span class="l7">.<span class="l9">.<span
class="l7">.<span class="l8">.<span class="l7">.<span class="l9">.<span class="l7">.<span
class="l8">.<span class="l8">.<span class="l8">.<span class="l7">.<span class="l8">.<span
class="l8">.<span class="l8">.<span class="l7">.<span class="l8">.<span class="l8">.<span
class="l8">.<span class="l7">.<span class="l8">.<span class="l8">.<span class="l8">.<span
class="l7">.<span class="l9">.<span
class="l7">)</span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></span></span></span></span></span></span></span></span></s
pan></span></span></span></div>
<div class="ff1" style="font-size:80px">
<span class="a" style="left:2564px;top:4165px;word-spacing:-1px">3. &lt;Nama Anak 2
dst..&gt; (…………….)</span><span class="a" style="left:370px;top:4272px;word-spacing:-
24px;letter-spacing:22px">U<span class="l" style="margin-left:-22px">m<span class="l"
style="margin-left:-22px">u<span class="l" style="margin-left:-22px">r<span class="w"
style="width:197px"></span>: <span class="l" style="margin-left:-20px">&lt;<span class="l"
style="margin-left:-22px">U<span class="l" style="margin-left:-22px">m<span class="l"
style="margin-left:-23px">u<span class="l" style="margin-left:-22px">r<span class="l"
style="margin-left:-
22px">&gt;</span></span></span></span></span></span></span></span></span></span><sp
an class="a" style="left:370px;top:4378px;word-spacing:-17px;letter-spacing:12px">A<span
class="l12">l<span class="l12">a<span class="l12">m<span class="l" style="margin-left:-
13px">a<span class="l12">t<span class="w" style="width:154px"></span>: <span
class="l7">&lt;<span class="l12">A<span class="l12">l<span class="l" style="margin-left:-
13px">a<span class="l12">m<span class="l" style="margin-left:-13px">a<span
class="l11">t<span class="l" style="margin-left:-
13px">&gt;</span></span></span></span></span></span></span></span></span></span></sp
an></span></span></span><span class="a" style="left:2021px;top:4804px">Mengetahui
:</span><span class="a" style="left:736px;top:5017px;word-spacing:-21px;letter-
spacing:20px">K<span class="l" style="margin-left:-20px">e<span class="l" style="margin-
left:-20px">p<span class="l" style="margin-left:-20px">a<span class="l" style="margin-left:-
20px">l<span class="l" style="margin-left:-21px">a <span class="l" style="margin-left:-
18px">D<span class="l" style="margin-left:-20px">e<span class="l" style="margin-left:-
20px">s<span class="l" style="margin-left:-20px">a <span class="l" style="margin-left:-
19px">&lt;<span class="l" style="margin-left:-21px">N<span class="l" style="margin-left:-
20px">a<span class="l" style="margin-left:-19px">m<span class="l" style="margin-left:-
21px">a <span class="l" style="margin-left:-18px">D<span class="l" style="margin-left:-
20px">e<span class="l" style="margin-left:-20px">s<span class="l" style="margin-left:-
20px">a<span class="l" style="margin-left:-20px">&gt;<span class="w"
style="width:916px"></span>K<span class="l" style="margin-left:-20px">e<span class="l"
style="margin-left:-20px">p<span class="l" style="margin-left:-19px">a<span class="l"
style="margin-left:-20px">l<span class="l" style="margin-left:-21px">a <span class="l"
style="margin-left:-18px">D<span class="l" style="margin-left:-20px">u<span class="l"
style="margin-left:-21px">s<span class="l" style="margin-left:-20px">u<span class="l"
style="margin-left:-20px">n<span class="l" style="margin-left:-20px">/<span class="l"
style="margin-left:-20px">L<span class="l" style="margin-left:-21px">u<span class="l"
style="margin-left:-19px">r<span class="l" style="margin-left:-21px">a<span class="l"
style="margin-left:-20px">h <span class="l" style="margin-left:-18px">&lt;<span class="l"
style="margin-left:-20px">N<span class="l" style="margin-left:-20px">a<span class="l"
style="margin-left:-20px">m<span class="l" style="margin-left:-20px">a <span class="l"
style="margin-left:-19px">D<span class="l" style="margin-left:-20px">u<span class="l"
style="margin-left:-20px">s<span class="l" style="margin-left:-20px">u<span class="l"
style="margin-left:-20px">n<span class="l" style="margin-left:-
21px">&gt;</span></span></span></span></span></span></span></span></span></span></sp
an></span></span></span></span></span></span></span></span></span></span></span></sp
an></span></span></span></span></span></span></span></span></span></span></span></sp
an></span></span></span></span></span></span></span></span></span></span></span></sp
an><span class="a" style="left:736px;top:5549px;word-spacing:982px;letter-spacing:-1px">(
<span class="l" style="margin-left:-30px">) <span class="l" style="margin-left:-249px">( <span
class="w" style="width:279px"></span>) </span></span></span><span class="a"
style="left:1714px;top:6082px;word-spacing:-1px">Camat &lt;Nama Kantor
Camat&gt;</span><span class="a" style="left:1695px;top:6614px;letter-spacing:-
1px">(………………………………)</span></div>
<div class="ff0" style="font-size:79px">
<span class="a" style="left:1091px;top:2014px;word-spacing:126px">Nama <span class="l"
style="margin-left:-131px">A<span class="l7">yah <span class="l" style="margin-left:-
125px">(Alm) <span class="w" style="width:206px"></span>+ <span class="w"
style="width:184px"></span>Nama <span class="l" style="margin-left:-
126px">Ibu</span></span></span></span></span><span class="a"
style="left:1414px;top:2329px;word-spacing:32px">1. <span class="l" style="margin-left:-
32px">Nama <span class="l" style="margin-left:-37px">Anak <span class="l" style="margin-
left:-32px">1 <span class="w" style="width:234px"></span>2. <span class="l" style="margin-
left:-32px">Nama <span class="l" style="margin-left:-37px">Anak <span class="l"
style="margin-left:-31px">2 <span class="l" style="margin-left:-
31px">dst…</span></span></span></span></span></span></span></span></div>
</div>
</div>
<div class="image_layer" style="z-index: 3">
<div class="ie_fix">
<img class="absimg" style="left: 294px; top: 94px; width: 362px; height: 52px; clip: rect(4px,
311px, 5px, 1px); display: block;" src="https://html1-
f.scribdassets.com/4ahqg2rxog60g5nr/images/1-c6aaf42146.png">
<img class="absimg" style="left: 216px; top: 414px; width: 362px; height: 52px; clip: rect(1px,
361px, 2px, 1px); display: block;" orig="http://html.scribd.com/4ahqg2rxog60g5nr/images/1-
c6aaf42146.png">
<img class="absimg" style="left: 382px; top: 417px; width: 362px; height: 52px; clip: rect(7px,
148px, 51px, 1px); display: block;" orig="http://html.scribd.com/4ahqg2rxog60g5nr/images/1-
c6aaf42146.png">
</div>
</div>
</div>