Lampiran 1

( Format 1 )
DAFTAR NAMA TENDIK YANG DIUSULKAN DARI SEKOLAH/TK
CALON PENERIMA DANA HIBAH DARI PEMERINTAH PROVINSI DKI JAKARTA
TAHUN 2021

NAMA SEKOLAH / TK :
ALAMAT SEKOLAH / TK :
NOMOR TELEPON SEKOLAH / TK :
KECAMATAN : SETIABUDI
KOTA/ KABUPATEN : JAKARTA SELATAN

Nama Pendidik Mata Pelajaran Yang Jumlah Dana Jumlah Yang

No NIK Usia Asal Sekolah NPSN NPWP Nomor rekening Jumlah Bulan Jumlah Dana PPh 21
(Guru) Diajarkan *) Per Bulan Diterima
1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 TITIN AGUSTINA - 3174084808940001 27 TKIT AL - MUGHNI 69831037 84.380.923.7-061.000 150.23.06475.0 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
2 HELMIYANAH - 3171076209800007 41 TKIT AL - MUGHNI 69831037 79.014.720.1-077.000 150.23.06476.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
3 ETI SUMIATI - 3175035207800008 41 TKIT AL - MUGHNI 69831037 46.597.389.9-002.000 507.23.05566.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
4 SALMAH - 3174024811710001 49 TK AR RAHMAN MOTIK 69831048 58.039.221.5-011.000 432.23.04565.9 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
5 SITI CHOTIPAH - 3171034306670004 53 TK AR RAHMAN MOTIK 69831048 58.039.228.0-027.000 150.23.06589.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
6 IIS KOMALAYANI - 3171016104670002 53 TK AR RAHMAN MOTIK 69831048 58.039.220.7-025.000 150.23.06339.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
7 MALINI KAWALIA - 3174096106750008 45 TK AR RAHMAN MOTIK 69831048 58.039.224.9-017.000 127.23.50157.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
8 INAYAH - 3174014606800009 40 TK AR RAHMAN MOTIK 69831048 58.039.229.8-015.000 542.23.00121.3 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
9 NENENG KURNIATI - 3175066212780011 41 TK AR RAHMAN MOTIK 69831048 58.039.230.6-006.000 125.23.09639.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
10 EVA FARIHAH - 3216025909810003 40 TK AR RAHMAN MOTIK 69831048 58.039.232.2-006.000 604.23.14980.0 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
11 KURNIA CHAERINA - 3275086908800024 41 TK AR RAHMAN MOTIK 69831048 58.039.231.4-432.000 537.23.11023.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
12 Nurhayati Artiningsih, SE, S.Pd - 3174025709750000 44 TK TANWIRUL QULUB 69831038 78.407.863.6-011.000 150.23.04047.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
13 Kholifah, S.Pd - 3174085407790000 41 TK TANWIRUL QULUB 69831038 55.929.401.2-061.000 405.20.03158.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
14 SITI CHODIJAH LATIEF, S.Pd.I 3174024407650000 55 TKIT AR-RAHMAN SAHARJO 69831042 58.039.223.1-018.000 103.23.01788.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
15 NURHASANAH, S.Pd.I 3174085502820000 38 TKIT AR-RAHMAN SAHARJO 69831042 49.589.359.6-014.001 433.23.06893.2 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
16 SITI MAHFUDHO, S.Pd 3171046402880000 32 TKIT AR-RAHMAN SAHARJO 69831042 66.098.943.5-023.000 433.23.06892.4 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
17 KHOLILAH MALESSY, S.Pd.I 3174015709670001 53 TKIT AR-RAHMAN SAHARJO 69831042 69.666.760.9-015.999 402.23.23528.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
18 EVA BENTONITA, S.Pd 3174084301880003 33 TKIT AR-RAHMAN SAHARJO 69831042 77.652.205.4-061.000 433.23.06894.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
19 Mona Titasari - 3174025210830002 37 TK AISYIYAH 37 69831045 84.136.293.2-018.000 402.23.18121.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
20 Yuli Nurwahyuningrum - 3175025407800001 41 TK AISYIYAH 37 69831045 82.216.583.3-003.000 153.23.11766.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
21 Lilo Susilowati - 3174084402830001 38 TK AISYIYAH 37 69831045 95.689.888.6-001.000 506.23.59819.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
22 Rizkita Kurnia Putri - 3175024107960001 24 TK AISYIYAH 37 69831045 70.938.062.0-003.000 539.23.07584.5 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
23 NURLAILI, S. Pd - 3174025309760005 44 TK ISLAM ARAFAH 69831043 97.166.117.8-018.000 432.23.04560.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
24 YAYAH NURLIAH, S. Pd. I - 3174025209820005 38 TK ISLAM ARAFAH 69831043 97.226.327.1-018.000 432.23.04558.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
25 NURLAILAH - 3174015006730007 47 TK ISLAM ARAFAH 69831043 78.350.166.1-015.000 127.23.50266.3 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
26 ASMANI - 3171064208840002 36 TK ISLAM ARAFAH 69831043 45.160.297.3-071.000 432.23.04559.4 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
27 Diah Huriah, S.Pd - 3174026407740003 47 TK DAARUL ULUUM 69831039 07.562.636.6-011.000 150.23.06972.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
28 Afifah Fachru Millati - 3174045810950005 26 TK DAARUL ULUUM 69831039 84.409.482.1-011.000 150.23.06503.9 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
29 RACHMAWATI, S.PdI - 3174025610850000 35 TK DWI HARAPAN II 69831036 45.173.803.3-011.000 150.23.06504.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
30 NURUL HASANAH, S.Pd - 3174096202940007 27 TK DWI HARAPAN II 69831036 96.778.308.5-068.000 432.23.07965.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
31 RACHMAWATI, S.PdI - 3171074303750003 45 TK DWI HARAPAN II 69831036 73.974.562.8-072.000 113.23.13335.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
32 Elvi Widia, S.Pd.I - 3174024806720000 48 TK AISYIYAH 25 69831041 77.897.757.9-018.000 432.20.00926.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
33 Al Ikomah Bidari Chawa, S.Pd - 3174097011930007 27 TK AISYIYAH 25 69831041 66.091.472.2-017.000 432.20.01585.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
34 Jumaisah, S.Pd - 3175094809900011 30 TK AISYIYAH 25 69831041 80.866.127.6-009.000 523.23.15347.5 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
35 Aisyah Desyana Ramadhita - 3174026112991001 21 TK AISYIYAH 25 69831041 85.279.611.9-018.000 402.23.22733.0 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
36 Dra. Hj. Faizah Chairy, M.Si - 3174024101550002 66 TK ISLAM RPI 69831035 69.610.267.2-063.000 112.23.05627.4 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
37 Sarwati, S.Pd.I - 3174014504801001 40 TK ISLAM RPI 69831035 69.610.265.6-015.000 112.23.05623.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
 38 Sri Mulyati, S.Pd.I - 3174016009810009 39 TK ISLAM RPI 69831035 69.610.266.4-015.000 112.23.05624.0 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
39 DELIMA PANDIANGAN - 3175094304810005 40 TK KRISTEN IX PENABUR 20111560 78.008.732.6-009.000 150.23.06513.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
40 LIE SUEFUNG - 3171085409680001 52 TK KRISTEN IX PENABUR 20111560 59.479.680.7-024.000 160.23.00070.8 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
41 THERESIA SUPRIYATINI - 3174045209670004 53 TK KRISTEN IX PENABUR 20111560 59.485.896.1-017.000 150.23.06482.2 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
42 TANTI ELVINA BUL - 31743016212740020 47 TK KRISTEN IX PENABUR 20111560 59.485.919.1-034.000 101.23.09306.9 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
43 SRI EKO SOEBIYANTI - 3175054906690002 52 TK KRISTEN IX PENABUR 20111560 59.479.714.4-009.000 513.23.18119.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
44 ELEN RAPODITA SIMANJUNTAK - 1272054703910001 30 TK KRISTEN IX PENABUR 20111560 71.389.187.7-117.000 449.23.02146.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
45 RINA - 3175086805880008 32 TK KRISTEN IX PENABUR 20111560 97.291.971.6-005.000 417.20.10395.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
46 Cicih Sukarsih, S. Pd. I - 3174086107680004 52 TK Aisyiyah 13 69831040 68.204.707.1-061.000 404.23.20215.5 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
47 Nurmala Alawiyah, S. Pd - 3174024410860002 34 TK Aisyiyah 13 69831040 67.565.466.9-011.000 150.23.06511.0 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
48 Tuti Rohaeni, S. Pd. I - 3174045405800001 41 TK Aisyiyah 13 69831040 88.108.625.0-017.000 150.23.06507.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
49 Nuriah - 3174026306760004 44 TK Aisyiyah 13 69831040 07.564.368.4-011.000 432.23.05140.3 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
50 Hj. Siti Nabilah ,S.Pd.AUD - 3174025103700002 50 TK Almustaqiem 69831044 09.644.639.8-018.999 422.23.00041.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
51 Fina Alfina - 3174016912770008 43 Tk.Almustaqiem 69831044 97.227.441.9-015.009 422.20.02009.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
52 Nurjanah - 3174027101690003 51 Tk. Almustaqiem 69831044 97.227.437.7-018.000 422.20.01815.7 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
53 iwuk Sri wuryaningsih - 3174024707720006 48 Tk. Almustaqiem 69831044 97.227.439.3-018.000 422.20.01813.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
54 Mujiati - 3174025808760004 44 TK. Almustaqiem 69831044 97.227.438.5-018.000 422.20.01814.9 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
55 SUKMAWATI - 3171045909880001 32 TK Nurul Jihad 69785778 09.008.944.2-023.000 422.20.01777.1 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
56 Wahyu Eka Puji Astuti - 3174014311790011 41 TK Nurul Jihad 69785778 87.476.008.5-015.000 432.20.00761.6 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
57 Siti Hasanah - 3171044402850006 36 TK Nurul Jihad 69785778 46.320.558.3-018.000 422.20.01778.9 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000
58 Widiana Mulyani - 3501054110900003 30 TK Nurul Jihad 69785778 84.584.031.3-018.000 112.23.08619.0 Rp500,000 3 Bulan Rp1,500,000 Rp75,000 Rp1,425,000

Mengetahui, Jakarta, 17 Februaru 2021

Ketua PGRI Cabang Kecamatan Setiabudi Kepala TK

Drs. Idris Fadilah.M.M.Pd

NPA : 09050900470

Catatan :
1. Sekolah mengisi kolom 1 sd. 13
a. Kolom 1 s.d. 8 cukup jelas
b. Kolom 9 diisi Rp.500.000,-
c. Kolom 10 diisi 3 bulan
d. Kolom 11 diisi hasil pengalian kolom 9 x kolom 10
e. Kolom 12 diisi 5% x kolom 11
f. Kolom 13 diisi kolom 11 – kolom 12
2. Daftar diisi nama pendidik (guru) yang memenuhi persyaratan ditandatangani dan di stempel sekolah
3. Discan sesuai ketentuan yg ditetapkan dan diupload ke alamat web. pgri DKI
Lampiran 1
( Format 1 )
 DAFTAR NAMA TENDIK YA
CALON PENERIMA DANA HIBAH D
TA

NAMA SEKOLAH / TK :
ALAMAT SEKOLAH / TK :
NOMOR TELEPON SEKOLAH / TK :
KECAMATAN : SETIABUDI
KOTA/ KABUPATEN : JAKARTA SELATAN

No Nama Tendik Jabatan NIK Usia

1 2 3 4 5

1 Maulida Hasanah Tata Usaha 3276015109980016 22

2 Arinie Zidna Staf Administrasi 3275065312920007 28

3 AHMAD ARIF RAHMAN HAKIM Tenaga Administrasi 3174010708750008 45

4 Dedeh Saripah Pramubakti 3278074906790005 41

5 Idawati Tenaga Administrasi 3174025108720005 48

6 Fauzan, S.Kom Tata Usaha 3174021510810003 40

7 AHMAD FERY MATSIN, SE Pramubakti 3174020110610003 59

8 Siti Marnah Pramubakti 3174026703520002 68

9 Ciptaning Andika Setyarini, S.Psi Administrasi 3171034401820004 39

10 JULIA GRASCIA TATA USAHA 3174106207920005 28

11 Siti Rukayah Pramubakti 3272105511770002 43

Mengetahui,
Ketua PGRI Cabang Kecamatan Setiabudi

Drs. Idris Fadilah.M.M.Pd

NPA : 09050900470
AFTAR NAMA TENDIK YANG DIUSULKAN DARI SEKOLAH/TK
ENERIMA DANA HIBAH DARI PEMERINTAH PROVINSI DKI JAKARTA
TAHUN 2021

Jumlah Dana Jumlah

Asal Sekolah NPWP Nomor rekening
Per Bulan Bulan
6 7 8 9 10

TKIT AL-MUGHNI 91.092.533.8-067.000 164.23.00415.3 Rp 500,000 3 Bulan

TK AR RAHMAN MOTIK 73.430.137.7-407.000 436.23.09095.9 Rp 500,000 3 Bulan

TKIT AR-RAHMAN SAHARJO 59.070.847.5-015.000 402.23.24421.8 Rp 500,000 3 Bulan

TK AISYIYAH 37 84.733.913.2-018.000 150.23.07000.8 Rp 500,000 3 Bulan

TK ISLAM ARAFAH 84.664.839.2-018.000 422.23.04154.1 Rp 500,000 3 Bulan

TK DAARUL ULUUM 07.562.637.4-011.000 150.23.06494.6 Rp 500,000 3 Bulan

TK DWI HARAPAN II 47.680.321.8-063.000 103.23.07913.5 Rp 500,000 3 Bulan

TK AISYIYAH 25 84.670.814.7-018.000 402.20.11842.4 Rp 500,000 3 Bulan

TK ISLAM RPI 49.520.955.3-027.000 112.23.07223.7 Rp 500,000 3 Bulan

TK KRISTEN IX PENABUR 64.049.012.4-013.000 150.23.06969.7

Rp 500,000 3 Bulan

TK Nurul Jihad 84.671.293.3-015.000 422.20.01993.5 Rp 500,000 3 Bulan

 Jumlah Yang
Jumlah Dana PPh 21
Diterima
11 12 13

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Rp 1,500,000 Rp 75,000 Rp 1,425,000

Jakarta, 17 Februari 2021

Kepala TK
 DAFTAR SEKOLAH PENERIMA DANA HIBAH TAHUN 2021
TK KECAMATAN SETIABUDI

JUMLAH
NO KECAMATAN NAMA SEKOLAH JENJANG NPSN
GURU
1 2 3 4 5 6
1 Setiabudi TK Islam Arafah TK 69831043 4
2 Setiabudi TK Aisyiyah 37 TK 69831045 4
3 Setiabudi TK Aisyiyah 25 TK 69831041 4
4 Setiabudi TK Al Mustaqiem Aswaja TK 97831044 5
5 Setiabudi TK Kristen 9 Penabur TK 20111560 7
6 Setiabudi TKIT Al Mughni TK 69831037 3
7 Setiabudi TK Ar-Rahman Motik TK 69831048 8
8 Setiabudi TK Aisyiyah 13 TK 69831040 4
9 Setiabudi TK Dwi Harapan II TK 69831036 3
10 Setiabudi TK Ar-Rahman Saharjo TK 69831042 5
11 Setiabudi TK Islam RPI TK 69831035 3
12 Setiabudi TK Nurul Jihad TK 69785778 4
13 Setiabudi TK Daarul Uluum TK 69831039 2
14 Setiabudi TK TANWIRUL QULUB TK 69831038 2
TOTAL 58
AHUN 2021

JUMLAH
TOTAL
TENDIK
7 8
1 5
1 5
1 5
0 5
1 8
1 4
1 9
0 4
1 4
1 6
1 4
1 5
1 3
0 2
11 69