SURAT PERNYATAAN Saya yang betanda tangan di bawah ini: Nama Tempat tanggal lahir Alamat Agama Pekerjaan Suku Handpone
: .................................................... : .................................................... : .................................................... : .................................................... : .................................................... : .................................................... : .................................................... (Selaku Pihak Pertama)
Nama Tempat tanggal lahir Alamat Agama Pekerjaan Suku Handpone
: .................................................... : .................................................... : .................................................... : .................................................... : .................................................... : .................................................... : .................................................... (Selaku Pihak Kedua)
Sehubungan dengan ........................................................................................................................ .......................................................................................................................................................... .............................................................................................., maka kami kedua belah pihak sepakat untuk menyelesaikan permasalahan tersebut secara kekeluargaan dengan membuat pernyataan sebagai berikut: 1. .................................................................................................................................................... .................................................................................................................................................... 2. .................................................................................................................................................... .................................................................................................................................................... 3. .................................................................................................................................................... .................................................................................................................................................... 4. .................................................................................................................................................... .................................................................................................................................................... Demikian surat pernyataan ini kami buat dengan sebenar-benarnya dan atas kesadaran kami bersama tanpa ada paksaan, bujukan dan rayuan dari pihak manapun.
(Selaku Pihak pertama)
Kendari , ......... Maret 2019 (Selaku Pihak Kedua)
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