STATEMENT LETTER

The undersigned below :

Name : NAFSIYAH
Id No : 3510056203740002
Place/Date of Birth : Banyuwangi, October 19, 1974
Address : Dusun Krajan RT.002/RW.005 Village Wringinputih District
Muncar Banyuwangi Regency, East Java, Indonesia.
Phone Number : +62 859-3549-6381
Email Adress : nafsiyah2203@gmail.com

Hereby declare that :

1. The data in the Personal Data (DP) form is in accordance with the data in the documents I
have
2. Attach valid and correct documents

If in the future that the statement I make is not true, then I am responsible for all
consequences that arise and the consequences, whether criminal, civil or administrative.

Thus, I have made this Statement in a conscious state without any pressure from any party,
and I am willing to be prosecuted in court if it is later proven that this statement is not true.

Banyuwangi, November 20, 2022

Materai 10000

NAFSIYAH