PEMERINTAH KABUPATEN BIMA

KECAMATAN AMBALAWI
DESA TOLOWATA
Alamat : Jalan Lintas Bima – Wera Desa Tolowata Kec. Ambalawi Kab. Bima Kode Pos 84153

SURAT KETERANGAN
Nomor : 10.02.1/05 /VI/2022

Yang bertanda tangan dibawah ini Kepala Desa Tolowata, Kecamatan Ambalawi, Kabupaten Bima,
menerangkan warga tersebut di bawah ini :

STATUS
NO NAMA NIK NO. KK USULAN
PERNIKAHAN
1 SITI HAWA 5206105507800003 5206100512100003 PBI KAWIN
2 AHDAR 5206101401850001 5206101801220005 PBI KAWIN
3 KALISOM 5206104107691095 5206100309100002 PBI KAWIN
4 SUHARTI 5206104101970001 5206101502210002 PBI KAWIN
5 WULAN APRILIA 5206105004020001 5206101801220006 PBI KAWIN
6 EMILIA 5206106012881002 5206100204140004 PBI KAWIN
7 FATMA 5206104107641086 5206100112100006 PBI CERAI MATI
8 ABDULLAH 5206100107451081 5206101612170017 BPNT CERAI MATI
9 JAMIAH 5206104701570001 5206101005080282 PBI KAWIN
10 ABDUL AZIS 5206100107741084 5206100405110008 PBI BELUM KAWIN
11 NURSIDAH 5206104802740001 5206102911100010 PBI KAWIN
12 MARWAN 5206102508830001 5206100111110043 PKH KAWIN
13 FATMAH 5206104107691110 5206102710100001 PKH KAWIN
14 IMO 5206104107411001 5206100603080122 PBI CERAI MATI
15 TOPAN ERLANGGA 5206101810820001 5206100810200001 PKH KAWIN
16 SUKI RAMADOAN 5206090305940001 5206102711180001 PKH KAWIN
17 AZHAR 5206101702860002 5206102109120001 PKH KAWIN
18 HASNUN 5206100107781088 5206101005110025 PKH KAWIN
19 SURIATI 5206107112821018 5206101609190005 PKH KAWIN
20 NURDIN 5206100107701150 5206101005110094 BPNT KAWIN
21 ALMA'RUF 5206103112841018 5206100905110033 PKH KAWIN
22 AMIRUDIN 5206101202840001 5206100812090004 PKH KAWIN
23 IMAM NAWAWI 5206102108930001 5206103007210001 BPNT KAWIN
24 ADRUS 5206100302750001 5206100809090002 BPNT KAWIN
25 SIRAJUDIN 5206103112831008 5206102809090008 PKH KAWIN
26 BUDIMANSYAH 5206102407840003 5206102809090008 PKH KAWIN
27 KUSRIANTO 5206102605880001 5206102203140001 BPNT KAWIN
28 M. SAID 5206103112501027 5206100405110014 BPNT KAWIN
29 AHADIS 5206103112711029 5206100405110015 BPNT KAWIN
30 HUSNI 5206101212851006 5296101101220002 PKH KAWIN
31 MUHAMMAD ALFARIZI 5206101111110003 5206102404110072 PBI BELUM KAWIN
32 GITA SALSABILA 5206105312150001 5206101607090003 PBI BELUM KAWIN
33 ADIATMAN 5272031808850003 5206100206200003 PBI KAWIN
34 ARBIATI 5206104202821003 5206100206200003 PBI KAWIN
35 OFAN ARDIANSYAH 5206100104841004 5206102404110045 PBI KAWIN
36 JUMIATI 5206104611851003 5206102404110045 PBI KAWIN
37 FANI APRILIA 5206105404100002 5206102404110045 PBI BELUM KAWIN
38 ANGELINA SARI 5206106008180001 5206102404110045 PBI BELUM KAWIN
39 ARYANTO 5206102110861002 5206101712130002 PBI KAWIN
40 ASNI 5206105205871004 5206101712130002 PBI KAWIN
41 M. RESTU 5206100402120001 5206101712130002 PBI BELUM KAWIN
42 NURLAELAH 5206106011860001 5206101011170006 PBI CERAI HIDUP
 STATUS
NO NAMA NIK NO. KK USULAN
PERNIKAHAN
44 M. QADAFI 5206100804190002 5206101011170006 PBI BELUM KAWIN
45 NUR ANJELITA 5206104507981002 5206100202190013 PBI KAWIN
46 MUHAMMAD PURBA DUAZI 5206101202180002 5206100202190013 PBI BELUM KAWIN
47 ZULMAR 5206101705001002 5206100112200002 PBI KAWIN
48 NURMALA 5206105005990001 5206100112200002 PBI KAWIN
49 RAFA ALBIANSYAH 5206100508200001 5206100112200002 PBI BELUM KAWIN
50 ANWAR 5206100711860002 5206100208170005 PBI KAWIN
51 ARBIANI JAFAR 5206104511750001 5206100208170005 PBI KAWIN
52 MUHAMMAD RIZKI 5206100912180001 5206100208170005 PBI BELUM KAWIN
53 ANHAR 5206101208880003 5206100205110045 PBI KAWIN
54 RADIATUR RABAWIYAH 5206104107941096 5206100205110045 PBI KAWIN
55 JULYAN RAHMAT SUTAMI 5206101007120001 5206100205110045 PBI BELUM KAWIN
56 ANWAR 5206100202840001 5206100710090003 PBI KAWIN
57 USWATUN HASANATULLAH 5206105206090001 5206100710090003 PBI BELUM KAWIN
58 ARIF HIDAYATULLAH 5206101206090001 5206100710090003 PBI BELUM KAWIN
59 KHAERUL AZAM 5206100901140001 5206100710090003 PBI BELUM KAWIN
60 AIDA RAHSETIA ISLAMI 5206107103170001 5206100710090003 PBI BELUM KAWIN
61 HJ. IBO 5206107112451004 5206101207100012 PBI CERAI MATI
62 SUMIATI 5206107107860002 5206102910110006 PBI KAWIN
63 BAMBANG 5206103112881032 5206101905140002 PBI KAWIN
64 A. RAFIK 5206101212800001 5206102603110009 PBI KAWIN
65 MAEMUNAH 5206107112590018 5206100300751001 PBI KAWIN
66 ISMAIL 5206103012551004 5206102511100002 PBI KAWIN
67 JAMALUDIN 5206102911700001 5206102631110007 PBI KAWIN
68 AMINAH 5206104812601003 5206100711110008 PBI CERAI MATI
69 ANWAR 5206103112640048 5206102603110022 PBI BELUM KAWIN
70 NOVITA SARI 5206106909980001 5206101812170010 PBI KAWIN
71 EDY GUNAWAN 5206102312870001 5206102012100010 PBI KAWIN
72 AKBAR 5206103112861026 5206102105180003 PBI KAWIN
73 ALIMIN 5206103112751031 5206101005110040 PBI KAWIN
74 SURATMAN 5206100706810002 5206100905110061 PBI KAWIN
75 NURMI 5206104602620001 5206101612170018 PKH KAWIN
76 SAHLAN 5206102303880002 5206100905110067 PBI KAWIN
77 IJO 5206105209580001 5206102504160004 PKH CERAI MATI
78 ROHANA 5206104402010001 5206100812200001 PBI KAWIN
79 SUMANTIA 5206104503800001 5206100205110007 PBI KAWIN
80 ALIMUDIN 5206103112881022 5206101905110001 PBI KAWIN
81 ARYANTO 5206103112701028 5206103108100001 PBI KAWIN
82 UMRAN 5206101204760001 5206100408090002 PBI KAWIN
83 ADNAN 5206101008700001 5206100309100001 PBI KAWIN
84 ARDIANI 5206107112821008 5206100311080006 PBI KAWIN
85 AJHAR 5206103112851091 5206101104110004 PBI KAWIN
86 ENDANG SUSILAWATI 5206104708830004 5206102710150001 PBI KAWIN
87 HAMIDAH 5206107112571022 5206100112100005 PBI KAWIN
88 HAWSAH 5206107112841018 5206100112100005 PBI BELUM KAWIN
89 RAMDAN 5206104107891109 5206100205110030 PBI KAWIN
90 AISYAH TALITA JAHRAN 5206106309150001 5206100809150002 PBI BELUM KAWIN
91 LILIS SURYANTI, S.Pd 5205086805930001 5206100702180004 PBI KAWIN
PASHA MAHARDIKA IQBAL
92 5206101804180001 5206100702180004 PBI BELUM KAWIN
IHSAN
 NO NAMA NIK NO. KK USULAN
93 BURHANUDI 5206102507830001 5206100805120001PBI
94 AMNAH MARIANI 5206104103831003 5206100805120001PBI
95 AGUS RAHMAN 5206103105100002 5206100805120001PBI
96 NURLAILAH 5206104101771003 5206101711100001PBI
97 M. FITRAH RAMADHAN 5206101404091002 5206101711100001PBI
98 SUCI KUSMAWATI 5206105803960002 5206101801220005PBI
99 ZAKIR 5206103112741025 5206100905110066PBI
100 SUFAERAH 5206104502800001 5206100905110066PBI
101 DARWIS 5206070903930001 5206100209160001PBI
102 YULIATI 5206105303940001 5206100209160001PBI
103 TIARA 5206104211160001 5206100209160001PBI
104 ANWAR 7271010506860005 5206100603180001PBI
105 JUMRIATI 5206107112941004 5206100603180001PKH
106 ALJHUAN PRASETIA 5206103103170001 5206100603180001PBI
107 AFDAL 5206103009910001 5206101607190004PBI
108 ROSWATI 5206124409960001 5206101607190004PBI
109 NOVIANA WANDA PUSPITA 5206104911200001 5206101607190004PBI
110 ANHAR 5206101403900001 5206101910170004PBI
111 DINI ARICAHYATI 5206105809970001 5206101910170004PBI
112 NADHIFA CHAYRA RUMAISAH 5206105503210001 5206101910170004PBI

Bahwa benar warga tersebut di atas berdasarkan data dan keaadaan yang sebenarnya tergolong
keluarga Kurang Mampu/Miskin.

Maka dibuatkanlah surat keterangan ini sebagai syarat untuk pengusulan Data Terpadu
Kesejahteraan Sosial (DTKS)

Demikian surat keterangan ini dibuat dengan sebenarnya untuk diketahui dan dapat
dipergunakan sebagaimana mestinya.

Tolowata, 20 Juni 2022

Kepala Desa Tolowata

JUARDI HS, SH
NIAP. 2020 0124 145 10.02.1