HASIL CEK LAPANGAN

Dengan ini kami melaporkan bahwa pada tanggal …. / ….. / 2012

Kami telah melakukan cek lapangan terhadap :

Nama                           :

Alamat                        :

No. Telp / HP              :

Peruntukan                  :

Besarnya Pengajuan    :

Dengan hasil :

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

...............................................................................................................................

...................................................................................................................................

...............................................................................................................................

...............................................................................................................................

           

Yang Memberi Keterangan ( …………………….……………. )	Banjar, ………………………..2012 Petugas cek lapangan ( …………………….……………. )
Mengetahui, Ketua Tim Evaluasi Usulan Penerima Bantuan Hibah dan Bantuan Sosial Bagian Kesos Setda Kota Banjar Hj. E. KARYATI, S.Ip NIP. 19570710 198103 2 010