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Surat menetapkan lima komitmen utama: tidak pernah dihukum penjara berdasarkan putusan yang berkekuatan hukum tetap dengan ancaman minimal 2 tahun, tidak diberhentikan secara tidak hormat dari jabatan tertentu, tidak berkedudukan sebagai calon/pegawai yang disebut, tidak menjadi anggota atau pengurus partai serta tidak terlibat politik praktis, serta bersedia ditempatkan di seluruh wilayah NKRI atau negara lain yang ditetapkan instansi pemerintah. Pernyataan berlaku dengan konsekuensi proses hukum bila kemudian tidak benar, disertai materai dan tanda tangan.",{"@graph":63,"@context":111},[64,81,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,72,75,78],{"item":68,"name":69,"@type":70,"position":71},"https://docshare.wps.com","Home","ListItem",1,{"item":73,"name":9,"@type":70,"position":74},"https://docshare.wps.com/id/document/",2,{"item":76,"name":31,"@type":70,"position":77},"https://docshare.wps.com/id/document/penelitian-laporan/",3,{"item":79,"name":59,"@type":70,"position":80},"https://docshare.wps.com/id/document/appendix-iii-declaration-letter-5-points/230987/",4,{"url":79,"name":59,"@type":82,"image":83,"author":88,"headline":59,"publisher":91,"fileFormat":94,"inLanguage":57,"description":61,"dateModified":95,"datePublished":96,"encodingFormat":94,"isAccessibleForFree":97,"interactionStatistic":98},"DigitalDocument",{"url":84,"@type":85,"width":86,"height":87},"https://docshare.wps.com/thumbnails/appendix-iii-declaration-letter-5-points/230987.png","ImageObject",300,407,{"name":89,"@type":90},"Noah","Person",{"url":68,"name":92,"@type":93},"DocShare","Organization","application/pdf","2026-09-20","2026-09-10",true,{"@type":99,"interactionType":100,"userInteractionCount":80},"InteractionCounter",{"@type":101},"ViewAction",{"@type":103,"mainEntity":104},"FAQPage",[105],{"name":106,"@type":107,"acceptedAnswer":108},"Apakah surat ini memerlukan materai dan tanda tangan?","Question",{"text":109,"@type":110},"Ya. Surat menampilkan kolom materai 10.000 serta bagian tanda tangan untuk yang membuat pernyataan.","Answer","https://schema.org",{"og:url":79,"og:type":113,"og:title":59,"og:site_name":92,"og:description":61},"article",{"robots":115,"canonical":79},"index,follow",{"doc_id":117,"site_id":56},230987,1789057887,{"code":4,"msg":5,"data":120},{"doc_id":117,"user_id":121,"nickname":89,"user_avatar":122,"doc_module":4,"category_id":30,"category_name":31,"doc_title":59,"doc_description":61,"doc_content":123,"file_id":124,"file_url":125,"file_type":126,"file_size":127,"view_count":80,"is_deleted":4,"is_public":71,"is_downloadable":71,"audit_status":71,"page_count":71,"language":128,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":129,"faqs":130,"seo_title":131,"seo_description":61,"update_tm":118,"read_time":74},8796095462418,"https://ap-avatar.wpscdn.com/avatar/80000253c1241d02b47?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778826106357471780","Lampiran III Pengumuman  \nSURAT PERNYATAAN  \nYang bertanda tangan di bawah ini:  \nNama :  \nTempat dan Tanggal Lahir :  \nAgama :  \nAlamat :  \nDengan ini menyatakan dengan sesungguhnya, bahwa saya:  \n1. Tidak pernah dipidana dengan pidana penjara berdasarkan putusan pengadilanyang 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 sendiri atautidak dengan hormat sebagai calon PNS atau PNS, PPPK, prajurit Tentara Nasional Indonesia, anggota Kepolisian Negara Republik Indonesia, ataudiberhentikan tidak dengan hormat sebagai pegawai swasta atau pegawai lainnya antara lain pegawai Badan Usaha Milik Negara dan pegawai Badan Usaha Milik Daerah;  \n3. Tidak berkedudukan sebagai calon PNS, PNS, PPPK, prajurit Tentara Nasional Indonesia, atau anggota Kepolisian Negara Republik Indonesia;  \n4. Tidak menjadi anggota atau pengurus partai politik atau terlibat politik praktis;  \n5. Bersedia ditempatkan di seluruh wilayah Negara Kesatuan Republik Indonesia atau negara lain yang ditentukan oleh Instansi Pemerintah.  \nDemikian pernyataan ini saya buat dengan sesungguhnya dan saya bersedia dituntut di pengadilan serta bersedia menerima segala tindakan yang diambil oleh Instansi Pemerintah, apabila di kemudian hari terbukti pernyataan saya ini tidak benar.  \n…………. .…,….…………. .…  \nYang Membuat Pernyataan,  \nmeterai 10.000  \n(……………………………………..)","cbCaiduRrZt3ttU5","https://ap.wps.com/l/cbCaiduRrZt3ttU5","pdf",102928,"Indonesian","# Lampiran III\n## Surat Pernyataan (5 Poin)","[{\"question\":\"Apakah surat ini memerlukan materai dan tanda tangan?\",\"answer\":\"Ya. Surat menampilkan kolom materai 10.000 serta bagian tanda tangan untuk yang membuat pernyataan.\"}]","Lampiran III - Surat Pernyataan 5 Poin | PDF"]