Surat Pernyataan Halaman / Page 1 of 2

Letter of Statement Mrs. Yougan Simo Josaine

SURAT PERNYATAAN
LETTER OF STATEMENT


Yang bertanda tangan di bawah ini :
Herewith, I undersigned below

Nama :...............................................................................................
Name

Alamat di Kamerun :...............................................................................................
Address in Cameroon

Alamat di Indonesia :..............................................................................................
Address in Indonesia

No. Paspor :...............................................................................................
Passport Number


1. Dengan ini menyatakan bahwa anak yang dilahirkan di RSIA YPK Mandiri Tanggal 21 Juni
2011, Pukul 15:39 WIB, adalah benar anak Saya dari Ibu Yougan Simo Josiane dan Bapak
Gueleguede Sam-el-Nadine Michel sesuai Birth Certificate No.249/80 from Civil Status
Registration Center of Bafia, United Republic of Cameroon) sebagaimana copy
terlampir.

Declare that the child was born at YPK Mandiri Mother and Children Hospital on June 21
2011 at 03:39 PM is trully My Son, Mrs. Yougan Simo Josiane and Mr.Guele Guede Sam-
el-Nadine Michel (according to the attached birth certificate of Mr. Michel itself
No.249/80 from Civil Status Registration Center of Bafia, United Republic of Cameroon).

2. Apabila dikemudian hari ada yang mengakui keberadaan dimaksud maka RSIA YPK
Mandiri dibebaskan dari segala tuntutan hukum yang berlaku di Negara Indonesia
maupun di negara Kamerun. Dan Saya bertanggung jawab apabila ada tuntutan hukum
yang dimaksud.

Declare that above information is true and agree to be responsible if otherwise proven
as false in the future. Therefore YPK Mandiri Mother and Children Hospital does not
have responsibility if otherwise proven as false in the future
Surat Pernyataan Halaman / Page 1 of 2
Letter of Statement Mrs. Yougan Simo Josaine


Demikan surat pernyataan ini dibuat tanpa ada paksaan dari pihak manapun dan dibuat
dalam kondisi sehat walafiat
This statement letter is true and to be used as necessary.


Jakarta, 02 Juli 2011

Yang membuat pernyataan,
I undersigned ,


(Yougan Simo Josiane)

Saksi I Saksi II
Witnes I Witnes II



( ) ( )
Family Representative YPK Mandiri Hospital Officer







Statement Letter is provided for with the Indonesian and English Language. Where inconsistencies,
the meaning of the Indonesian language shall prevail.

Surat Pernyataan Halaman / Page 1 of 2
Letter of Statement Mrs. Yougan Simo Josaine