[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-230986-113":3,"detail-sidebar-cat-0-id-113":81,"doc-detail-230986-id":128},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},113,"id","5-point-declaration-letter","Surat Pernyataan 5 Poin","","This document outlines a standardized format for a five-point declaration letter, commonly used in official administrative processes within or related to the Tulang Bawang Barat Regency government. It details critical declarations required from an individual. Firstly, it asserts that the individual has no prior criminal convictions resulting in imprisonment for two years or more, based on a legally binding court decision. Secondly, it confirms the individual has not been honorably or dishonorably dismissed from roles such as civil servant (CPNS, PNS, PPPK), military personnel (TNI), or police officer (POLRI), nor have they been dishonorably dismissed from private sector employment, including state-owned or regional-owned enterprises. Thirdly, the statement clarifies that the individual is not currently holding a position as a civil servant, contract-based civil servant, military personnel, or police officer. Fourthly, it requires a declaration of non-affiliation with any political party or involvement in practical politics. Finally, the applicant commits to being willing to be placed anywhere within the Republic of Indonesia or other locations determined by the Tulang Bawang Barat Regency Government. The letter concludes with a solemn pledge that the statements made are true and that the individual is prepared for legal prosecution and any actions by the government should the declarations prove false. It requires the signature of the declarant, affixed with a meterai stamp, and includes fields for the declarant's name, place and date of birth, religion, address, and the date of the declaration.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/id/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/id/document/umum/","Umum",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/id/document/5-point-declaration-letter/230986/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/5-point-declaration-letter/230986.png","ImageObject",300,407,{"name":42,"@type":43},"Oliver","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-06","2026-09-10",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",5,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Apa saja lima poin utama yang harus dinyatakan dalam surat pernyataan ini?","Question",{"text":63,"@type":64},"Lima poin utama yang harus dinyatakan adalah: tidak pernah dipidana penjara minimal dua tahun, tidak pernah diberhentikan secara tidak hormat dari PNS/TNI/Polri/swasta, tidak berstatus sebagai PNS/TNI/Polri, tidak terlibat politik praktis, dan bersedia ditempatkan di seluruh wilayah NKRI atau negara lain yang ditentukan pemerintah.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Apa konsekuensinya jika pernyataan dalam surat ini terbukti tidak benar?",{"text":68,"@type":64},"Jika pernyataan dalam surat ini terbukti tidak benar, pembuat pernyataan bersedia dituntut di pengadilan dan menerima segala tindakan yang diambil oleh Pemerintah Kabupaten Tulang Bawang Barat.",{"name":70,"@type":61,"acceptedAnswer":71},"Siapa yang harus menandatangani surat pernyataan ini dan apa yang diperlukan?",{"text":72,"@type":64},"Surat pernyataan ini harus ditandatangani oleh orang yang membuat pernyataan dan wajib dibubuhi meterai senilai 10.000 untuk keabsahan hukumnya.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},230986,1790434246,{"code":4,"msg":82,"data":83},"success",[84,89,93,97,101,105,109,113,117,121,124],{"id":85,"doc_module":4,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},55,"Agama & Spiritualitas",60,"religion-spirituality",{"id":90,"doc_module":4,"doc_module_name":25,"category_name":91,"show_sort_weight":87,"slug":92},48,"Cerita & Novel","story-novel",{"id":94,"doc_module":4,"doc_module_name":25,"category_name":95,"show_sort_weight":87,"slug":96},56,"Gaya Hidup","lifestyle",{"id":98,"doc_module":4,"doc_module_name":25,"category_name":99,"show_sort_weight":87,"slug":100},51,"Komik","comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":87,"slug":104},53,"Layanan Kesehatan","healthcare",{"id":106,"doc_module":4,"doc_module_name":25,"category_name":107,"show_sort_weight":87,"slug":108},54,"Penelitian & Laporan","research-report",{"id":110,"doc_module":4,"doc_module_name":25,"category_name":111,"show_sort_weight":87,"slug":112},49,"Sastra","literature",{"id":114,"doc_module":4,"doc_module_name":25,"category_name":115,"show_sort_weight":87,"slug":116},52,"Teknologi","technology",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":119,"show_sort_weight":87,"slug":120},50,"Ujian","exam",{"id":122,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":87,"slug":123},57,"general",{"id":125,"doc_module":4,"doc_module_name":25,"category_name":126,"show_sort_weight":4,"slug":127},181,"Formulir","formulir",{"code":4,"msg":82,"data":129},{"doc_id":79,"user_id":130,"nickname":42,"user_avatar":131,"doc_module":4,"category_id":122,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":132,"file_id":133,"file_url":134,"file_type":135,"file_size":136,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":137,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":11,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":26},8796095461610,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","CONTOH FORMAT SURAT PERNYATAAN 5 (LIMA) POIN  \nSURAT PERNYATAAN  \nYang bertanda tangan dibawah ini :  \nNama :   (nama lengkap + gelar) Tempat dan tanggal lahir :   (disesuaikan)  \nAgama :   (disesuaikan)  \nAlamat :   (disesuaikan)  \nDengan ini menyatakan dengan sesungguhnya, bahwa Saya :  \n1. Tidak pernah dipidana dengan pidana penjara berdasarkan putusan pengadilan yang sudah mempunyai kekuatan hukum tetap karena melakukan tindak pidana dengan pidana penjara 2 (dua) tahun atau lebih.  \n2. Tidak pernah diberhentikan dengan hormat tidak atas permintaan sendiriatau tidak hormat sebagai CPNS, PNS, PPPK, TNI , POLRI ataudiberhentikan tidak dengan hormat sebagai Pegawai Swasta (termasuk BUMN/BUMD) .  \n3. Tidak berkedudukan sebagai CPNS/PNS, PPPK atau Anggota TNI/POLRI.  \n4. Tidak menjadi anggota/pengurus partai politik atau terlibat politik praktis.  \n5. Bersedia ditempatkan diseluruh wilayah Negara Kesatuan Republik Indonesia atau Negara lain yang ditentukan oleh Pemerintah Kabupaten Tulang Bawang Barat.  \nDemikian pernyataan ini saya buat dengan sesungguhnya, dan saya bersedia dituntut di pengadilan serta bersedia menerima segala tindakan yang diambiloleh Pemerintah Kabupaten Tulang Bawang Barat. , apabila dikemudian hari terbukti pernyataan saya ini tidak benar.  \n  ,   September 2025  \nYang membuat pernyataan  \nMeterai 10.000  \n(ttd)  \n(nama lengkap + gelar)","cbCaiffh0yHX2jcP","https://ap.wps.com/l/cbCaiffh0yHX2jcP","pdf",135651,"Indonesian","[{\"question\":\"Apa saja lima poin utama yang harus dinyatakan dalam surat pernyataan ini?\",\"answer\":\"Lima poin utama yang harus dinyatakan adalah: tidak pernah dipidana penjara minimal dua tahun, tidak pernah diberhentikan secara tidak hormat dari PNS/TNI/Polri/swasta, tidak berstatus sebagai PNS/TNI/Polri, tidak terlibat politik praktis, dan bersedia ditempatkan di seluruh wilayah NKRI atau negara lain yang ditentukan pemerintah.\"},{\"question\":\"Apa konsekuensinya jika pernyataan dalam surat ini terbukti tidak benar?\",\"answer\":\"Jika pernyataan dalam surat ini terbukti tidak benar, pembuat pernyataan bersedia dituntut di pengadilan dan menerima segala tindakan yang diambil oleh Pemerintah Kabupaten Tulang Bawang Barat.\"},{\"question\":\"Siapa yang harus menandatangani surat pernyataan ini dan apa yang diperlukan?\",\"answer\":\"Surat pernyataan ini harus ditandatangani oleh orang yang membuat pernyataan dan wajib dibubuhi meterai senilai 10.000 untuk keabsahan hukumnya.\"}]","Surat Pernyataan 5 Poin | PDF",1789057886]