SURAT PERNYATAAN KESEDIAAN PEMINDAHBUKUAN REKENING BRI KE BSI

Saya yang bertandatangan di bawah ini:

Kesediaan
Pemindahbukuan
Nama Peserta rekening
No. Nama Orang Tua/Wali NISN NIK Peserta didik Kelas Nomor Rekening Tanda Tangan Orang Tua/Wali
Didik
Tidak
Bersedia
Bersedia

AHMAT
1 SUSANTO 0050632616 1175022709050001 9 217501013667507
BERUTU

2 DEBY JUITA 0061855680 1175021305060001 9 217501008512505

FANDIYES
3 0062992913 1175020710060001 9 217501009083509
HULU

ISMALUM
4 0062790761 1175021801060002 9 217501006229504
BERUTU

MARZUKIAMAN
5 0057384183 1175012312050001 9 217501013669509
B

6 RICHA BANCIN 0056426473 1175022905050002 9 217501016343500

SRI
7 0051510340 1175025806050002 9 217501013456508
HANDAYANI

BOIRMAN
8 0036889667 1175012510030001 9 217501016962508
SYAHPUTRA
 IMANSYAH
9 0045671015 1110122202040004 9 780301006174507
MUDDRA

KHAIRUN
10 ANNISAH 0064845870 1175026204060001 9 217501016938509
BERUTU

NOFIKA BR
11 0053063643 1175024711050002 9 217501008303508
PASARIBU

SITI
12 0061886738 1175026511060001 9 217501008281502
NURHAYATI

TENGKU AYU
13 0066990271 1175024109060001 9 217501016861508
AISYAH PUTRI

14 ABDUL MAJIT 0025949411 1175020303080001 7 217501009248507

15 DENI APRIYADI 0063048874 1175020204060001 9 217501008307502

FERI
16 0064031230 1175020202060001 9 217501016329506
ARDIANSYAH

JAMARDIN
17 0074106952 1175021002070001 9 217501013710504
BANCIN

MULIANA BR
18 0063225852 1175024804060002 9 217501016392509
BERUTU

RINDAWATI
19 0052494228 1175025907060001 9 217501006237507
TINAMBUNAN
 SRI MEI
20 0052298011 1175026005050002 9 217501008590503
JUMIATI TELAU

WAHYU ALPIAN
21 0068281229 1175021912060001 9 217501009112502
ANGKAT

BAMBANG
WIDODO
22 0063774465 1175022007060001 9 217501006419507
SAHPUTRA
BANCIN

23 ILHAM BANCIN 0058431497 1175022311050001 9 217501006268508

KARINA
24 0044631746 1175026807040001 9 217501006924502
SARAAN

NADIA
25 0069366906 1175026212060001 9 217501009162507
WULANDARI

26 SANJAIDUT 0051564465 1175021612050001 9 217501013721505

ABDI
27 SULAIMAN 0079041208 1175022411070002 7 217501008457501
UJUNG

RAJA MUDA
28 0084972650 1175020107080002 7 217501006057509
BANCIN

29 APRIANI SOLIN 0063697063 1175024604060002 9 217501006327506

DESI
30 PURNAMA 0062815658 1175025302060002 9 217501005755502
SITUMORANG
 HALALDI
31 0064919489 1175020907060001 9 217501016427508
BANCIN

JODI
32 PRANANDA 0068816745 1204142606060001 9 217501013508509
LASE

MURLINA
33 0043866492 1175025405040003 9 217501013668503
NDURU

34 RISKA SOLIN 0047477862 1175025508040002 9 217501016956507

35 SUGIANTO 0043815681 1175023012040001 9 217501008950509

AZIS PRAMANA
36 0054875688 1175021011050002 9 217501006053505
CIBRO

37 HERIYANTO 0057955591 1175021508050003 9 217501006401504

JULI
38 ALAMSYAH 0062542102 1175022607060001 9 217501016935501
PUTRA ANGKAT

39 MUTIA ZAHRA 0052010150 1175026604060001 9 217501016226504

40 RISNO BANCIN 0068360621 1175022104060001 9 217501008064502

SYAHFITRI
41 0073897504 1175025410060002 9 217501016345502
RAMADANI
 YULIANA BR
42 0058276670 1175024407050001 9 217501006200500
BERUTU

AHMAD SYAH
43 0076791830 1175021101070001 9 217501008594507
PUTRA SOLIN

DAHLIANI
44 0057089493 1175024611050001 9 217501013455502
ANGKAT

EVA
45 FATMAWATI 0062123461 1175024902060001 9 217501016416507
TANJUNG

MARLINA
46 0045876225 1175024202040001 9 217501011712500
MANIK

RIANTO
47 0063702666 1175022411060001 9 217501008408502
BERUTU

TITIN SURYANI
48 0068290952 1175025512060001 9 217501016881508
SARAAN

AKBAR
49 0082586263 1175021112080001 7 217501006355509
BANUREA

AZZAHRA
50 0082327464 1175026505080002 7 217501008911505
PINAYUNGAN

51 FAHRIZAL 0071640494 1175022509070002 7 217501008736507

LENA SURIANI
52 0072495944 1175026511070001 7 217501008462506
BANCIN
 NATASIA
53 RAMADANI 0072898684 1175025609070002 7 217501008154501
BANCIN

RANTI YULI
54 0075798686 1175024511070001 7 217501009143503
SHAFIRA

ROLY OKVIKA
55 0077092526 1175022510070001 7 217501009316504
HUTASOIT

YULIANA
56 0079452677 1216016206070001 7 217501009754508
TUMANGGOR

ALMIAH DECA
57 0089332716 1175026607080002 7 217501006326500
ISTIFARAH

DIANA
58 RAMADANI 0074997087 1175025909070001 7 217501005811502
MANIK

MAULANA
59 IHSANUL 0072593205 1175023011070001 7 217501008427506
HAKIM BANCIN

PERDI
60 ALPRIJAN 0084190600 1175020401090001 7 217501008169506
SAGALA

RIFAI RAHMAD
61 0077269088 1175021411070001 7 217501008043506
FAHROZI

SURIANI
62 0088319198 1175026704080001 7 217501008967506
MANIK

ADVEN
63 HARAPAN 0063482707 1215061412060002 8 537601003232509
MANIK
 ROBAH
64 0050632615 1175022508050001 7 217501005969509
BANCIN

65 YULI SAFITRI 0086930066 1175024307080001 7 217501008810505

ANANDA ANAK
66 0076748441 1175025501080002 8 217501016376503
AMPUN

FAHREZI
67 0078162671 1175021607070001 8 217501016867504
BERUTU

RIDHO
68 RIZKYTA 0063722013 1175022601070001 8 217501017011504
SARAAN

TOGAR RAJOKI
69 0081835652 1175022501080001 8 217501016968504
RAMBE

70 TRIA AGUSTIN 0067135895 1175025008060001 9 217501017012500

71 ALFINA 0071534092 1175024906070002 7 217501008720506

DEVI ARYADI
72 0078673856 1175020412070001 7 217501006404502
TUMORANG

HENDRI
73 0086677715 1175023108080001 7 217501008969508
AGUSTO

MAHMUDIN
74 0089089815 1175023107080001 7 217501009753502
CIBRO
 RIDWANSYAH
75 PUTRA 0083777363 1175020608080001 7 217501008529502
BANUREA

ADREA EGY
76 0074019571 1175021406070001 8 217501016300502
PALANSA

WAN AHO
PARNINGOTAN
77 0062750087 1175021503060001 9 217501016874501
SIRINGO
RINGO

ELLA
78 0041907639 1175026107070001 7 217501008015503
MULYANTI

JON
79 MORGANDA 0073505577 1175022104070002 7 217501009304507
MANALU

80 ULIL AKBAR 0088364138 1175020704080001 7 217501009177502

81 AHMAD 0055734715 1222031111050005 8 217501016243506

EMI LESTARI
82 0076023008 1175024907070001 8 217501016303500
SITUMORANG

HESTI
83 ANJELITA BR 0074322758 1175026101070001 8 217501014090509
BERASA

ERNA
84 LASMARITO BR 0072162933 1175025210070002 7 217501005997502
SIHOTANG

KAHARUDDIN
85 0089762782 1175020804080001 7 217501008561504
CIBRO
86 MAY SHINTA 0089462167 1175024505080005 7 217501008239505

RADITIA
87 0083145813 1175021806080001 7 217501005695508
ISLAMI MAHA

RIZKINA
88 AGUSTIN 0087793890 1175026908080001 7 217501008644506
BERUTU

AHMAD ARIS
89 0062592452 1175022602060001 8 217501016389506
TRIONO

EVLANDO
90 0055880261 1175021106060001 8 217501006081508
SIREGAR

ZAHRA
91 0068727136 1175024708060001 9 217501017115502
AGUSTIA

ANGGI
92 0079345164 1175025807070001 8 217501005864505
TUMANGGER

MAY SARAH
93 0069547079 1175024510060002 8 217501016923504
CIBRO

RIDUANSYAH
94 0072554054 1175020610070002 8 217501016400506
CAPAH

TUBAGUS
95 0079784639 1175022404070002 8 217501016296509
RAFFI AKBAR

DANI
96 0073809196 1175021705070001 8 217501005965505
RAHMANSYAH
 HERI
97 0062995231 1175021309060001 8 217501016866508
RUDIANSAH

SAPRIL
98 ALFAJAR 0069534780 1175022704060001 8 217501016988504
BRASA

99 ZAHARA FAJRI 0072330367 1175026504070001 8 217501016969500

100 DESI RAHAYU 0063116449 1103104212060004 7 217501008243504

PARADIVA
101 0088186957 1175026210080001 7 217501008420504
ZAITUN

SANTA PUTRI
102 0089616365 1175024405080003 7 217501016639503
OLIVIA LAIA

ZULKIFLI
103 0064159372 1175020912060002 7 217501008365500
CIBRO

ANNISHA
104 0074681586 1175026707070001 8 217501016225508
SABRINA

FITRI NISTIA
105 0067121724 1175025810060001 8 217501016870507
WATI PASI

UJANG
106 0073584478 1175020609070001 8 217501005734506
RAMADANI

DAMIANA
107 NOVERLINA 0066808223 1214075711060005 8 803901003602507
GIAWA
 GABRIEL JHON
108 0077851182 1175022903070001 8 217501016298501
SENA BERASA

109 SABRI S 0074455777 1175020201070001 8 217501017045503

UYUNG
110 0078128627 1175020411080001 8 217501016301508
BERUTU

M SLAMET
111 0082336198 1175021808080001 8 217501009771500
NURABIDIN

112 REVENDI 0076143363 1175022309070003 8 217501016875507

SINTA FATIOLA
113 0077292879 1175024407070001 8 217501016895507
T

114 ADITIA MANIK 0056786605 1175021703050001 9 217501016310507

CAHYA WULAN
115 0066827142 1175024411060001 9 217501008040508
PRATIWI

116 ETINA GEA 0053789587 1175026109060002 9 217501006348502

IMELSAH
117 HAYATI 0051917086 1175025602060001 9 217501009322505
TUMANGGER

M ALDI
118 RAMADHANI 0051872430 1175023110050001 9 217501016322504
BERUTU
 NOFIYANTI BR
119 0053004457 1175024711050001 9 217501016860502
PASARIBU

SITI
120 0069240352 1171026709060001 9 391701001605502
RAHMADANI

121 TIO SHAPUTRA 0073867820 1175022307070003 9 217501008407506

NIA
122 RAMADHANI 0088892197 1175026209080001 7 217501008465504
BERUTU

123 RENDI HAKIM 0084208307 1175012504080001 7 217501005947507

SADARMAN
124 0073532155 1175021501080002 7 217501008415509
NDURU

ZAQI FIRMAN
125 0061024700 1175021011060002 7 217501008897507
SYAH

ANISA BR
126 0078259213 1175020112070001 8 217501014109502
BANCIN

FAJRIANSYAH
127 0079523734 1175021606070001 8 217501017056504
LUBIS

MEI
128 RATNAWATI BR 0077131859 1175045905070001 8 217501016944500
SINAGA

TULUS
129 SADARIAH BR 0072877501 1175024606070001 8 217501016996507
BERUTU
Adalah benar merupakan orang tua/wali dari peserta didik sesuai dengan tabel di atas, menyatakan:

1. pemindahbukuan rekening SimPel Bank Rakyak Indonesia (BRI) ke rekening Bank Syariah Indonesia (BSI) sesuai dengan kolom kesediaan
pemindahbukuan rekening di atas untuk penyaluran dana bantuan Program Indonesia Pintar;dan
2. saldo yang dipindahkan adalah sesuai dengan saldo terakhir pada saat rekening dblokir yang ada direkening SimPel BRI.

Demikian, surat pernyataan ini agar digunakan sebagaimana mestinya.

..............., ................

*ceklis pilih salah satu kolom(bersedia atau tidak bersedia)