BPJS Baru

FORM MIGRASI PESERTA
JENIS PESERTA
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KODE VIRTUAL ACCOUNT
BANK TEMPAT PEMBAYARAN IURAN
TANGGAl REGISTRASI
NOMOR PKS
KODE PKS
MASA BERLAKU
KODE TANGGUNGAN
KODE KC
KODE DATI2
Jenis Status
Kode HubKel Tgl Lahir
Kelamin Kawin
1 = Peserta
No No KK NIK/KITAS/KITAP Nama Lengkap 0=TD
2 = Suami
1=L 1=B,
3 = Istri Tempat Lahir dd/mm/yyyy
2=P 2=K,
4 = Anak
3=C
5 = Tambahan
1 2 3 4 5 6 7 8 9
1 1812012507110035 1812011908710001 Sadino 2 Bandar Jaya 19-08-1971 L K
2 1812010906120001 1812016108890003 Sumarni 3 Panaragan 21-08-1988 P K
4 1812011609140004 1812016804870009 Aprina 3 Kota Bumi 28-04-1987 P K
6 1812011804120066 1812017010540002 Harlini 3 Penumagan 30-10-1954 P K
7 1812012302120005 1812012507060003 Amar Maruf 2 Pulung Kencana 25-07-2006 L B
8 1812041306120039 1812042102060001 Rendi Suranto 4 Gunung Agung 21-02-2006 L B
9 1812072106110005 1812076512710002 Romiyati 3 Metro 25-12-1971 P K
10 1812012909140013 1812015303920004 Ferawati 3 Panaragan 10/3/1992 P K
12 1812042805130054 1812045012590005 Prawoto 2 Jawa Tengah 19-11-1940 L K
13 1812070801150001 1812074401910005 Pujiatin 4 Gunung Sari 4/1/1991 P K
14 1812031009130006 1812031207650011 Sulaiman 2 Karta 7/12/1965 L K
15 1812031009130006 1812030404950002 Dwi Purnama 4 Kagungan ratu 4/4/1995 P B
KETERANGAN : CONTOH PENGISISAN
1812876667
Kode
Kode Kode Desa Kode
Alamat Tempat Tinggal RT RW Kecamatan Nama Kecamatan Nama Desa
Pos (diisi petugas) Faskes Tk.I
(diisi petugas)
10 11 12 13 14 15 16 17 18
Candra Kencana 04 02 Tulang Bawang Tengah Candra Kencana
Panaragan 01 06 Tulang Bawang Tengah Panaragan
Penumangan 01 03 Tulang Bawang Tengah Penumangan
Penumangan 01 03 Tulang Bawang Tengah Penumangan
Pulung Kencana 06 03 Tulang Bawang Tengah Pulung Kencana
Gunung Agung 20 05 Gunung Terang Gunung Agung
Kibang Yekti Jaya 18 06 Lambu Kibang Kibang Yekti Jaya
Bandar Dewa 06 03 Tulang Bawang Tengah Panaragan
Marga Sari 05 01 Gunung Terang marga sari
Pagar Jaya 11 03 Lambu Kibang pagar jaya
Kagungan ratu 02 05 Tulang Bawang Udik Kagungan ratu
Kagungan ratu 02 05 Tulang Bawang Udik Kagungan ratu
Status Kelas Rawat
Kode Nomor 1=Tetap, Gaji Pokok +

Nama Faskes TMT Kerja
Nama Faskes Tk.I Faskes Telepon Email NIP Jabatan 2=Kontrak, 1=Kelas I, Tunj. Tetap
Dokter Gigi Dokter Gigi (Kary. Aktif)
Peserta 3=Paruh waktu 2=Kelas II, (Kary. Aktif)
4=Penerima 3=Kelas III
Pensiun
19 20 21 22 23 24 25 26 27 28 29
Mulya Asri
Panaragan
Panaragan
Panaragan
Mulya Asri
Toto Mulyo
Kibang Budi Jaya
panaragan
Toto Mulyo
Kibang Budi Jaya
Kartaraharja
Kartaraharja
Mengetahui,
Pimpinan Perusahaan
(............................)
Kewarga
Negaraan Asuransi Lainnya
No
No. NPWP Passport
1=WNI, Nama
No. Kartu Asuransi
2=WNA Asuransi
30 31 32 33 34
Mandiri nunggak
Mandiri nunggak
Mandiri nunggak
Mandiri nunggak
JENIS PESERTA
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TANGGAl REGISTRASI
NOMOR PKS
KODE PKS
MASA BERLAKU
KODE TANGGUNGAN
KODE KC
KODE DATI2
Jenis Status
Kelamin Kawin
1 = Peserta
No No KK NIK/KITAS/KITAP Nama Lengkap 0=TD
2 = Suami
1=L 1=B,
2=P 2=K,
4 = Anak
3=C
5 = Tambahan
1 2 3 4 5 6 7 8 9
1 1812032503150003 1812031608870001 SYAMSUDIN 2 KARTA 16/08/1987 1 2
2 1812032503150003 1812036410950002 ANISA OKTAVIA 3 KARTA 24/10/1995 2 2
3 1812032503150003 1812036407150002 AISYAH JASMIN 4 KARTA 24/07/2015 2 1
4 1812031208110008 1812030507740003 SURYA DARMA 2 KARTA 05/07/1974 1 2
5 1812031208110008 1812036006770002 LINDA WATI 3 KARTA 20/06/1977 2 2
6 1812031208110008 1812031602040002 RYANDA AGMA PUTRA 4 KARTA 16/02/2004 1 1
7 1812031208110008 1812031101060004 ADJI GUSMANDA 4 KARTA 11/01/2006 1 1
8 1812031101160002 1812035212650006 DARNA 1 KARTA 13/12/1965 2 3
9 1812031101160002 1812035702920003 SANTINA FAREZA 4 KARTA 17/02/1992 2 1
10 1812031001140004 1812032008790003 HUSIN SABARA 2 KARTA 20/08/1974 1 2
11 1812031001140004 1812035410870006 OKTA YANI 3 KOTABUMI 14/10/1987 2 2
12 1812031001140004 1812032011070001 RIDHO AGMA PRATAMA 4 KARTA 23/11/2007 1 1
13 1812031001140004 1812031110130004 WAHYU WHANDIRA 4 KARTA 01/10/2013 1 1
14 1812031804120011 1812030704780004 KASWANTO 2 RUMBIA 07/04/1978 1 2
15 1812031804120011 1812035212820007 WINARSIS 3 KARTA 12/12/1982 2 2
16 1812031804120011 1812032703100001 TEGAR WAHYU WINATA 4 KARTA 27/03/2010 1 1
17 1812030203117092 1812030606700001 A RIDUAN US 2 KARTA 06/06/1970 1 2
18 1812030203117092 1812035204730003 KOMALA SARI 3 KOTABUMI 12/04/1973 2 2
19 1812032307150005 1812030407890004 HERI YANTO 2 KARTA 04/07/1988 1 2
20 1812032307150005 1812034507880004 ABINA SARI 3 NEGARA KEMAKMURAN 05/07/1988 2 2
21 1812032307150005 1812032209150001 RAHMADHA AGMA PUTRA 4 KARTA 22/09/2015 1 1
22 1812031704120020 1812032606420001 AGUS MARGA 2 KARTA 26/06/1942 1 2
23 1812031704120020 1812036804450001 MAS RIPAH 3 KARTA 28/04/1945 2 2
24 1812031704120020 1812031403760003 AUGA LITA 4 KARTA 14/03/1976 1 1
25 1812031704120020 1812031004830004 SURATMAN 4 KARTA 10/04/1983 1 1
26 1812031704120020 1812031508850005 SUDIRMAN 4 KARTA 15/08/1985 1 1
27 1812031910150001 1812034407700008 MAHDALIA 1 KARTA 04/07/1970 2 3
28 1812031910150001 1812035601980006 JESSY ROSALIA 2 KARTA 16/01/1988 2 1
29 1812030406130002 1812030508670001 SUMARDI RS 2 KARTA 05/II/1969 1 2
30 1812030406130002 1812036105690001 SUNYATI 3 KARTA 10/12/1965 2 2
31 1812030406130002 1812032705950003 MURSAN SANJAYA 4 KARTA 27/05/1995 1 1
32 1812030406130002 1812036707960003 SISKA AGUSTINA 4 KARTA 27/07/1996 1 1
33 1812030406130002 1812030404010004 KAMARUDIN PATAH 4 KARTA 04/04/2001 1 1
34 1812030203117311 1812030201650001 SUKUR 2 KARTA 02/01/1965 1 2
35 1812030203117311 1812035011670001 YUSNI 3 KARTA 01/11/1967 2 2
36 1812030203117311 1812031511920002 FEROSI 4 KARTA 16/11/1992 1 1
37 1812030203117311 1812035207960003 VERA ERVIYANA 4 KARTA 07/12/1996 2 1
38 1812030203117311 1812034504980001 NELLY NIRWANA 4 KARTA 05/04/1998 2 1
39 1812030203117311 1812030805030002 HERLANI 4 KARTA 08/08/2003 1 1
40 1812030203117311 1812035507070005 OPY ASTRIKA 4 KARTA 15/07/2007 2 1
41 1812030506120008 1812031107690003 SUHARDI 2 KARTA 11/07/1969 1 2
42 1812030506120008 1812034808710004 GUSTI SEVEN 3 KOTABUMI 08/08/1971 2 2
43 1812030506120008 1812030907880001 JAUSAL ILLYAS GIANTARA 4 KARTA 19/07/1999 2 1
44 1812030506120008 1812030512040003 JAYA ILLYAS GIANTARA 4 KARTA 10/12/2005 1 1
45 1812030506120008 1812036308090001 ANNISHA ROMADHONA 4 KARTA 23/08/2009 2 1
1812032704120015 1812031011870002 DARSANI 2 KARTA 10/11/1987 1 2
1812032704120015 1812034207920006 MARDIANA 3 PANARAGAN 02/07/1992 2 2
1812032704120015 1812032510120006 AHMADANI PUTRA SANJAYA 4 KARTA 25/10/2012 1 1
1812032411110020 1812034701640002 ASNAWATI 1 KARTA 07/01/1964 2 2
1812032411110020 1812034708840007 SARI ASTUTI 4 KARTA 07/08/1984 2 1
1812032411110020 1812036306880001 RIA ASTRIDA 4 KARTA 23/06/1988 2 1
1812032411110020 1812036306880001 M UNTUNG JP 4 KARTA 17/02/1992 1 1
1812032411110020 1812035407000002 RIKA SARTIKA 4 KARTA 14/07/2000 2 1
1812032411110018 1812030510500003 TUAN SEDJATI 2 KARTA 05/10/1950 1 2
1812032411110018 1812034907600004 MEGAWATI 3 KARTA 09/07/1960 2 2
1812032411110018 1812035002920002 SAMAINI 4 KARTA 10/02/1992 2 1
1812031811140001 1812034108490004 JELIYAH 1 KARTA 01/08/1949 2 C
1812031811140001 1812031005790005 MISWANDA 4 KARTA 10/05/1979 1 1
1812033009130013 1812032402540001 KASTAM 2 KARTA 09/09/1950 1 2
1812033009130013 1812036505700003 ASNILA 3 KARTA 25/05/1970 2 2
1812033009130013 1812031505880008 SAWALUDIN 4 KARTA 15/05/1988 1 1
1812033009130013 1812032802900007 RESWANTO 4 KARTA 28/02/1990 1 1
1812033009130013 1812031908990003 SOMAD SALSABILA FIRDAUS 4 KARTA 19/08/1999 1 1
1812033009130013 1812032805070001 LUTFI AZIZ 4 KARTA 28/05/2007 1 1
1812033009130013 1812032905130001 ZAKARIA 4 KARTA 29/05/2013 1 1
1812031405120005 1812032905760004 SUBIR 2 KARTA 29/05/1976 1 2
1812031405120005 1812034407820004 ELDA RIYANTI 3 KARTA 04/07/1982 2 2
1812031405120005 1812034101070004 ELVIRA CANTIKA ILHAM 4 KARTA 01/01/2007 2 1
1812031405120005 1812032705100001 RIDHO 4 KARTA 27/05/2010 1 1
1812032706130003 1812031508640004 RADEN 2 KARTA 01/07/1963 1 2
1812032706130003 1812034505660003 CIK YAH 3 KARTA 06/07/1966 2 2
1812032706130003 1812031406970001 RICKY ARIYANSYAH 4 KARTA 14/06/1997 1 1
1812031602150004 1812032710990001 ALBERT FRANCISCO 2 KARTA 29/10/1999 1 2
1812031602150004 1812036203990005 SUNDARI MARDANIA 3 KARTA 22/03/1999 2 2
1812031601120005 1812031810720002 MASRI NUR 2 KARTA 18/01/1972 1 2
1812031601120005 1812034205730003 NURMAILI 3 KARTA 02/05/1973 2 2
1812031601120005 1812031304930005 ADITYA TAMA 4 KARTA 13/04/1993 1 1
1812031601120005 1812035203980003 MERIAM 4 KARTA 11/03/1998 2 1
1812031601120005 1812036411010004 ANISA 4 KARTA 24/11/2001 2 1
1812031601120005 1812034110320002 HJ. CIKNUN S.MEGA 5 KARTA 01/10/1932 2 2
1812030504130001 1812030107790059 SUBERI 2 KARTA 01/07/1979 1 2
1812030504130001 1812034403760003 MARYANTI 3 KOTABUMI 04/03/1976 2 2
1812030203117649 1812030107600015 RAYUAN 2 KARTA 01/07/1960 1 2
1812030203117649 1812034512700001 MARYATI 3 KARTA 05/12/1970 2 2
1812030203117649 1812030107670019 SUMANTRI 4 KARTA 01/07/1987 1 1
1812030203117649 1812030107960026 AKMALUDIN 4 KARTA 01/07/1996 1 1
1812030203117649 1812030107990062 AHMAD 4 KARTA 01/07/1999 1 1
1812031807130004 1812033012720004 ALI USMAN 2 KARTA 30/12/1972 1 2
1812031807130004 1812034801700011 FATMAWATI 3 KARTA 08/01/1970 2 2
1812031807130004 1812036012090002 ALMA CLARA DESTA 4 KARTA 20/12/2009 2 1
1812031807130004 1812032803110001 ALVIN ZEZA DIAGO 4 KARTA 28/03/2011 1 1
1812030203116920 1812030712760001 SOLDA 2 KARTA 07/12/1975 1 2
1812030203116920 1812034107740022 HAIDA 3 KARTA 07/12/1976 2 2
1812030203116920 1812034309970001 SRI INDAH PRATIWI 4 KARTA 03/09/1997 2 1
1812030203116920 1812032806990001 AHMAD SAMPURNA 4 KARTA 28/06/1999 1 1
1812030901150006 1812030501500007 SAINI 2 KARTA 05/10/1950 1 2
1812030901150006 1812034107670032 ROHIDA 3 KARTA 01/07/1967 2 2
1812030901150006 1812034107880062 SRI LESTARI 4 KARTA 06/10/1989 2 1
1812030901150006 1812034107930061 YUNIA SARI 4 KARTA 01/07/1993 2 1
1812032902120002 1812032604770002 BAHIDI 2 KARTA 26/04/1977 1 2
1812032902120002 1812036101820003 JUHAINI 3 KARTA 21/01/1982 2 2
1812032902120002 1812034909030004 ANDINI SEPTIANI 4 KOTABUMI 09/09/2003 2 1
1812032902120002 1812032107080001 ANDIKA WAHYU PRATAMA 4 KOTABUMI 21/07/2008 1 1
1812032411110012 1812030503770001 TURUNAN MUL 2 KARTA 05/03/1977 1 2
1812032411110012 1812036811820002 RESMAWATI 3 KARTA 28/11/1982 2 2
1812032411110012 1812030304990005 RISTORI 4 KARTA 03/04/1999 1 1
1812032411110012 1812032704000003 RIAN PRANATA 4 KARTA 27/04/2000 1 1
1812032411110012 1812032807030003 RIKO PRAYOGA 4 KARTA 28/07/2003 1 1
1812032411110012 1812030308050005 RIKI PRANANDA 4 KARTA 03/08/2005 1 1
1812032411110012 1812030307860004 M SIKIN 5 KARTA 03/07/1986 1 1
1812032411110012 1812036205940001 JUWITA 5 KARTA 22/05/1994 2 1
1812032907130004 1812032705770001 NAWAN 2 KARTA 27/05/1977 1 2
1812032907130004 1812036605850002 LINDA JANYUS 3 KARTA 26/05/1985 2 2
1812032907130004 1812032709050002 HAFIZH NANDA PRATAMA 4 KARTA 27/09/2006 1 1
1812032907130004 1812036005130002 SALSABILA NANDA PUTRI 4 KARTA 20/05/2013 2 1
1812031805120010 1812031710800004 SYAMSUL BAHRI 2 KARTA 17/10/1980 1 2
1812031805120010 1812036504810004 RITA APRILIANI 3 KARTA 25/04/1981 2 2
1812031805120010 1812035210080001 AZAHRATASYA OCTAVIANA 4 KARTA 12/10/2008 2 1
1812032012110019 1812030408690001 SUJONO 2 LUMAJANG 04/08/1969 1 2
1812032012110019 1812034711740001 IDA MARYANA 3 KOTABUMI 07/11/1984 2 2
1812032012110019 1812030909940001 SEPTIADI 4 LUMAJANG 10/09/1995 1 1
1812031211120002 182030602780003 ADI EFFENDIA 2 KARTA 06/02/1978 1 2
1812031211120002 1812035011790005 ROSMADEWI 3 KARTA 11/11/1979 2 2
1812031211120002 1812030311070003 REFAN PUTRA ADISMA 4 KARTA 03/11/2007 1 1
1812031211120002 1812032110120001 ILHAM DANI PUTRA ADISMA 4 TULANG BAWANG BARAT 21/10/2012 1 1
1812032506120005 1812034101910004 EPI DARLI 3 CAMPANG JAYA 01/01/1991 2 2
1812033007110001 ALFAT SYAHMEGA 4 KARTA 30/07/2011 1 1
1812030701100064 1812032004510001 MITO 2 METRO 20/04/1951 1 2
1812034202530001 BIBIT SUPRIHATIN 3 KEBUMEN 02/02/1953 2 2
1812032005890001 KISNANTO 4 KARTA SARI 20/05/1989 1 1
1812030403111975 1812030712660001 SOLEHUDIN 2 MAJALENGKA 07/12/1966 1 2
1812035203770004 PAINI 3 METRO 12/03/1977 2 2
1812036203010003 VIKI RAHMA WATI 4 DAYA MURNI 22/03/2001 2 1
1812031402100002 DZIDAN ABDUL LATIF 4 KARTA RAHARJA 14/02/2010 1 1
1812031902140003 1812031107820006 SUTIKNO 2 KARTA SARI 11/07/1982 1 2
1812035310840005 MARMI 3 WAY SIDO 13/10/1984 2 2
1812036607080001 FANY RAHAYU 4 WAY SIDO 26/07/2008 2 1
1812030902140001 IRFAN FADHIL 4 TULANG BAWANG BARAT 09/02/2014 1 1
1812030105120012 1812031205420004 AMANSYAH 2 KARTA 12/05/1942 1 2
1812034512500001 TULIN 3 KARTA 05/12/1950 2 1
1812034505810008 MAYSAROH 4 KARTA 05/05/1981 2 1
1812030607150013 1803071609860001 HEPPI PUTRA 2 SINAR OGAN 16/11/1986 1 2
1812034211810001 HENI SUSANTI 3 KARTA 02/11/1981 2 2
1812034704140002 APRILLIA NADA ALLIZHA 4 JAKARTA 07/04/2014 2 1
1812031703150009 1812032311750002 SUWANTO 2 KARTA SARI 23/11/1975 1 2
1812035006790007 SUPARMI 3 METRO 10/06/1979 2 2
1812032509990005 HARIS PRAYOGA 4 KARTA SARI 24/09/1999 1 1
1812031409070001 DIYON AKA SAPUTRA 4 KARTA SARI 07/04/2007 1 1
1812035811840002 1812030507780002 ALI MUDIN 2 KARTA 05/07/1978 1 2
1812035811840002 APRIDA RESTIANA 3 KARTA 18/11/1984 2 2
1812031210090003 CHAQAL ARSYAD 4 BANDAR JAYA 12/10/2009 1 1
1812030603120001 KUKUH ARSYAD 4 MARGA KENCANA 06/03/2012 1 1
1812031811130002 1812031210720004 SODIKIN 2 KARTA 12/10/1972 1 2
1812036104710007 INDRA YANI 3 KARTA 21/04/1971 2 2
1812030806960004 SANDRA WIJAYA 4 KARTA RAHARJA 08/06/1996 1 1
1812030302010004 TRIO FEBRIYANSAH 4 KARTA RAHARJA 03/02/2001 1 1
1812030203117559 1812030107580024 AMIRUDIN 2 KARTA 01/07/1958 1 2
1812034109600004 DARSITA 3 KARTA 01/09/1960 2 2
1812035409900006 RESMALA DEWI 4 KARTA 14/09/1991 2 1
1812030605930001 BUDI SATRIA 4 KARTA 06/05/1993 1 1
1812036309940002 DINA RIKA PUTRI 4 KARTA 23/09/1996 2 1
1812036809970002 SUCI SANTRI INDAH 4 KARTA 28/09/1997 2 1
1812032608990005 PAHADA SAPUTRA 4 KARTA 26/08/1999 1 1
1812032308110003 1812035504730005 DAHLIA 1 KOTABUMI 15/04/1973 2 3
1812032408930001 SOPIYAH SAH 4 KOTABUMI 24/08/1993 1 1
1812030705010003 KOHAR 4 KOTABUMI 07/05/2001 1 1
1812030102040003 PENDI 4 KOTABUMI 01/02/2004 1 1
1805040910080004 1805043012700004 KARIM 2 KARTA 30/12/1970 1 2
1805045310670001 DAYURI 3 KARTA 13/10/1967 2 2
1805040505880002 AGUS NADI RIYANTO 4 KARTA 05/05/1988 1 1
1805045010910001 HERWANISAH 4 KARTA 10/10/1991 2 1
1805046511920001 KEMALA DEWI 4 KARTA 25/11/1992 2 1
1805046509990003 PEBRI SUSANTI 4 KARTA 25/09/1999 2 1
1805042601040001 JAUHARI SAPUTRA JAYA 4 KARTA 26/01/2004 1 1
18120313066160006 1812030107910073 AGUS NADI PRIYANTO 2 KARTA 01/07/1991 1 2
1812034604990004 EVI YANI 3 BLAMBANGAN 06/04/1999 2 2
1812035804140001 CHIKA PRISA 4 KARTA 18/04/2014 2 1
1812012602117008 1812010904650001 ATMOJO 2 KEDIRI 09/04/1965 1 2
1812015209700001 MURTININGSIH 3 METRO 12/09/1970 2 2
1812011505960005 VERY WICAKSONO 4 CANDRA KENCANA 15/05/1996 1 1
1812014407000001 SUMIATI 4 CANDRA KENCANA 04/07/2000 2 1
1812012708150003 1812015510560001 MARIYEM 1 SOLO 15/10/1956 2 3
1812012003850008 DEDI SANTOSO 4 CANDRA KENCANA 20/03/1985 1 1
1812010102120093 1812013107260001 SUWANDI 2 YOGYAKARTA 31/07/1926 1 2
1812015905340001 SARINEM 3 JEMBER 19/05/1934 2 2
1812012702110544 1812010704840004 MASRURI 2 CANDRA KENCANA 07/04/1984 1 2
1812014609870003 ISTIAMAH 3 DAYA MURNI 06/09/1987 2 2
1812015107060001 INKA SHALUM SALSABILA 4 LAMPUNG TENGAH 11/07/2006 2 1
1812010102120089 1812011406740002 SUWARNO 2 KEDIRI 14/06/1974 1 2
1812015007830008 WANTINEM 3 CANDRA KENCANA 10/07/1983 2 2
1812014401050003 RARA PUTRI NABILLA 4 GUNUNG MADU 04/01/2005 2 1
1812010302120019 1812011508570002 BOMAN 2 SOLO 15/08/1957 1 2
1812014409660006 MARLIYAH 3 TEMANGGUNG 04/09/1966 2 2
1812012807900003 SUTRISNO 4 CANDRA KENCANA 28/07/1990 1 1
1812012702110548 1812011110720002 SUARNO 2 KALIANDA 16/06/1978 1 2
1812014501730003 DEWI SANTIANI 3 CANDRA KENCANA 28/05/1981 2 2
1812015408040003 AJENG SETIA PUTRI 4 CANDRA KENCANA 14/08/2004 2 1
1812010202120061 1812015509710007 SUMIATI 1 BANDAR JAYA 15/09/1971 2 2
1812015204970006 ANA LESTARI 4 CANDRA KENCANA 12/04/1996 2 1
1812010212130004 TEGAR SETIAWAN 4 CANDRA KENCANA 02/12/2013 1 1
1812011608160023 1812011004640012 SUMADI 2 BLITAR 10/04/1964 1 2
1812015208790012 SUGIARTI 3 BUMI NABUNG ILIR 12/08/1979 2 2
1812015311060003 FIBRIYANA LEONATA 4 BUMI NABUNG ILIR 13/11/2006 2 1
1812010209070000 SURYA BAGUS SEPTIAN 4 GUNUNG MADU 02/09/2007 1 1
1812012602118011 1812011612620001 MARKHABAN 2 METRO 16/12/1962 1 2
1812015010680016 JAMILAH 3 METRO 10/10/1968 2 2
1812010404980004 TRI SISWANTO 4 CANDRA KENCANA 04/04/1998 1 1
1812022711150004 1812022809930002 ARGA EVENDI SEPTIAN 2 SURABAYA 01/09/1993 1 2
1812014607950003 ARUM LESTARI 3 CANDRA KENCANA 06/07/1995 2 2
1812011412150001 FATHIR AGAM EFENDI 4 LAMPUNG TENGAH 14/12/2015 1 1
1812022506120071 1812020508560002 SUMARNO 2 SOLO TIGA 05/08/1956 1 2
1812024204610001 SUMINI 3 SOLO TIGA 02/04/1961 2 2
1812022012110022 1812020608620001 SUKIRAN 2 KEDIRI 06/08/1962 1 2
1812025710520001 JARMI 3 KEDIRI 17/10/1952 2 2
1812021310140001 1812021005860007 KUAT WIYONO 2 WAY TEBU 10/05/1986 1 2
1812025209920003 ISAH SEPTI ROHANA 3 DAYA SAKTI 12/09/1992 2 2
1812022708140017 1812022805830007 HERI TUPANTO 2 DAYA SAKTI 28/05/1983 1 2
1812025004860011 SITI NURALISAH 3 TEGAL 10/04/1986 2 2
1812020707070005 MUHAMMAD ABDUL DEDE I 4 TEGAL 07/07/2007 1 1
1812020603120032 1812020710550005 KOLIDUN 2 PURWOREJO 07/10/1955 1 2
1812025103600003 MISINI 3 KEDIRI 11/03/1960 2 2
1812025810030002 UUT WAHYUNI 4 DAYA SAKTI 18/10/2003 2 1
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1812025607890003 ETA SURYANI 3 KARTA RAHARJA 16/07/1989 2 2
1812023009980001 REVAL WAHYU RAMDANI 4 KARTA RAHARJA 30/09/1998 1 1
1812022709120001 FALLENDRA ARKA VINCENTYAS 4 TULANG BAWANG BARAT 27/09/2012 1 1
1812022105120038 1812020411830003 SUMARYADI 2 DAYA MURNI 04/11/1983 1 2
1812025206880006 RAWIK RANTAWIYANI 3 JAWA TENGAH 12/06/1988 2 2
1812021306070001 TITO ANANTA 4 DAYA MURNI 13/06/2007 1 1
1812020103117841 1812020711670004 SURATMAN 2 KLATEN 07/11/1967 1 2
1812024304720004 SUPARMI 3 TANJUNG BINTANG 03/04/1972 2 2
1812024802980001 RAHMADAYANTI ARYADINATA 4 TULANG BAWANG 08/02/1998 2 1
1812022610050001 AGENG DANUARTA RAMADHAN 4 TULANG BAWANG 26/10/2005 1 1
1812022403160008 1812034807790003 HILMIYATI 1 JOMBANG 03/07/1973 2 2
1812022604120064 1812021502200003 MODO 2 BLITAR 15/02/1920 1 2
1812024605320003 SARTUMI 3 JAWA TENGAH 06/05/1932 2 2
1812026405700005 KARTINI 4 SRIKATON 24/05/1970 2 1
1812021805800004 MULYADI 4 SRIKATON 18/05/1980 1 1
1812025505850009 SUNDARI 4 SRIKATON 15/05/1985 2 1
1812021505880003 SISWOYO 4 SRIKATON 15/05/1988 1 1
1812022802115583 1812020709500001 NARMAN 2 TALANG PADANG 07/09/1950 1 2
1812024206550001 SUNTIAH 3 SERANG 02/06/1955 2 2
1812024606870003 PUJI YARTI 4 TALANG PADANG 06/06/1987 2 1
1812021605120110 1812023112540003 SUMINTO 2 KLATEN 31/12/1954 1 2
1812026110600003 SUYATMI 3 KLATEN 21/10/1960 2 2
1812022010900006 BENY SUYANTO 4 KLATEN 20/10/1991 1 1
1812022505120010 1812020406580003 ROSIKIN 2 KARTA 04/06/1958 1 2
1812025807610003 HERMAYATI 3 KARTA 18/07/1961 2 2
1812025411000004 HERLINA NOVITA SARI 4 DAYA MURNI 14/11/2000 2 1
1812022402040004 REZKI FEBRIYANSAH 4 DAYA MURNI 24/02/2004 1 1
1812020608150011 1812022603870004 CHAIRULLAH 2 DAYA MURNI 26/03/1987 1 2
1812025011910001 NIA FITRIANI 3 DAYA MURNI 10/11/1991 2 2
1812022201140003 1812020505620006 MARZUKI 2 PADANG PARIAMAN 05/05/1962 1 2
1812024705650011 DARNILIS 3 PADANG PARIAMAN 07/05/1965 2 2
1812026012960002 IRA PUSPITA SARI 4 LAMPUNG UTARA 20/12/1996 2 1
1812023008160023 1812025408460001 HALIMAH 2 KARTA 14/08/1946 1 2
1812023012790002 DARMANTO 3 KOTA BUMI 30/12/1979 2 2
1812023007120015 1812021903790002 ABDUL HANNAS 2 PADANG 19/03/1979 1 2
1812026808820010 DEWI AGUSTIN 3 KOTA BUMI 28/08/1982 2 2
1812020706050003 AGHNASRUL FADHLI 4 KARTA RAHARJA 07/06/2005 1 1
1812022508160007 1812026301680004 ROHELA BETA 1 KARTA 23/01/1968 2 3
1812023006890003 JON HERTOBI 4 KOTA BUMI 30/06/1989 1 1
1812026311920002 NUR HERTATI 4 KOTA BUMI 23/11/1992 2 1
1812025712940002 DESI HERTINI 4 KOTA BUMI 17/12/1994 2 1
1812022403980001 HERSAN TORI YUSUF 4 KOTA BUMI 24/03/1998 1 1
1812022302120092 1812020403570005 ABDUL RAUF 1 PADANG 04/03/1957 1 3
1812026909920005 RITA SAFTIANAH 4 DAYA MURNI 29/09/1992 2 1
1812024405960005 AFINI 4 DAYA MURNI 04/05/1996 2 1
1812024605000005 ASMITA DEWI SANTI 4 DAYA MURNI 06/05/2000 2 1
1812025707060002 SULFI ANDRIANI 4 DAYA MURNI 17/07/2006 2 1
1812023012110034 1812022505830004 EFENDI 2 MEDAN 25/051983 1 2
1812025007890009 WESI LESNI 3 DAYA MURNI 10/07/1989 2 2
1812026708120001 ASYFA NADILA 4 DAYA MURNI 27/08/2012 2 1
1812020103118380 1812026087100003 NASRI 2 PADANG 06/08/1971 1 2
1812024402730001 NUR HILAL 3 DAYA MURNI 04/02/1973 2 3
1812021711010003 ISHMAT TAMRU HKALIS 4 DAYA MURNI 17/11/2001 2 1
1812021904050001 MUHAMMAD ADIB 4 DAYA MURNI 19/042005 1 1
1812022704120019 1812021212590011 PURNOMO 2 KERTO SOWO 12/12/1959 1 2
1812024904690005 MUSRIATI 3 PRINGSEWU 09/04/1969 2 2
1812020406890012 DENI PRIANGGORO 4 DAYA MURNI 04/06/1989 1 1
1812026303940005 AISAH SARI 4 DAYA MURNI 23/03/1994 2 1
1812024104970004 DIAN APRILIYANI 4 DAYA MURNI 01/04/1997 2 1
1812020705000003 IRFAN ROHMANELFANDO 4 DAYA MURNI 07/05/2000 1 1
1812025310040002 DEVINDA 4 DAYA MURNI 13/10/2004 2 1
1812022310070001 BARBARA ROYAN ROHIS ZAKI 4 DAYA MURNI 23/10/2007 1 1
1812031501100098 1812031607540001 SAMPIR 2 LAMPUNG TIMUR 16/071954 1 2
1812034801620001 PURWATI 3 JAWA TENGAH 08/01/1962 2 2
1812031806130005 1812031506860006 IMAM KHOIRI 2 REJO SARI 15/06/1986 1 2
1812036904900004 IIN INDRAWATI 3 LAMPUNG UTARA 28/04/1990 2 2
1812032504130001 KAAFI DZIKIR AL KHOIRI 4 DAYA MURNI 25/04/2013 1 1
1812032004110009 1812032103600001 EDI SUBAGIO 2 MENGGALA 21/03/1960 1 2
1812035409650001 RASITI 3 LAMPUNG SELATAN 14/09/1965 2 2
1812031904010001 RANGGA MUHAMAD NASRUL 4 KARTA SARI 19/04/2001 1 1
ERVINA MAULIDHA
ARISKA
SULIYONO
TRI HATMIRAH
H. MUHRON
AHMAD AN
ARMEN LUBIS
1812021008160009 1812027110810002 HARYAN

Kode Kode Desa Kode
Alamat Tempat Tinggal RT RW Kecamatan Nama Kecamatan Nama Desa Nama Faskes Tk.I
(diisi petugas) Faskes Tk.I
(diisi petugas)
10 11 12 13 14 15 16 17 18 19
KARTA 001 001 TULANG BAWANG UDIK KARTA DAYAMURNI
KARTA 004 001 TULANG BAWANG UDIK DAYAMURNI
KARTA SARI 008 002 TULANG BAWANG UDIK DAYAMURNI
KARTA 02 01 TULANG BAWANG UDIK
KARTA 02 01
KARTA 04 04
KARTA 04 04
KARTA 04 04
KARTA 04 04
KARTA 04 04
KARTA 04 04
KARTA 04 04
KARTA 04 04
KARTA 03 04
KARTA 03 04
KARTA 03 04
KARTA 04 04
KARTA 04 04
KARTA 01 04
KARTA 01 04
KARTA 01 04
KARTA 01 04
KARTA 01 04
KARTA 01 04
KARTA 01 04
KARTA 03 03
KARTA 03 03
KARTA 03 03
KARTA 03 03
KARTA 02 02
KARTA 02 02
KARTA 02 02
KARTA 04 04
KARTA 04 04
KARTA 03 03
KARTA 03 03
KARTA 03 03
KARTA 03 03
KARTA 03 03
KARTA 03 03
KARTA 04 04
KARTA 04 04
KARTA 01 04
KARTA 05 TULANG BAWANG UDIK
CANDRA MUKTI 01 01 TULANG BAWANG UDIK
DAYA SAKTI 20 07 TULANG BAWANG UDIK
DAYA MURNI 03 02 TULANG BAWANG UDIK
DAYA ASRI 04 05 TULANG BAWANG UDIK
MURNI JAYA 01 02 TULANG BAWANG UDIK
MULYA ASRI 04 03 TULANG BAWANG UDIK
MARGA KENCANA 10 02 TULANG BAWANG UDIK
DAYAMURNI 03 01 TULANG BAWANG UDIK
GUNUNG TIMBUL 02 01 TULANG BAWANG UDIK
KARTA SARI 07 02 TULANG BAWANG UDIK
MAKARTI 02 01 TULANG BAWANG UDIK
MULYA JAYA 16 03 TULANG BAWANG UDIK
MULYA JAYA 16 03 TULANG BAWANG UDIK
MULYA KENCANA 01 04 TULANG BAWANG UDIK
CANDRA KENCANA 07 02 TULANG BAWANG UDIK
MENGGALA MAS 01 01 TULANG BAWANG UDIK
DAYA MURNI TULANG BAWANG UDIK
KARTA SARI TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
TULANG BAWANG UDIK
Status Kelas Rawat Kewarga
Negaraan Asuransi Lainnya
Faskes Telepon Email NIP Jabatan 2=Kontrak, 1=Kelas I, Tunj. Tetap No. NPWP
Dokter Gigi Dokter Gigi (Kary. Aktif) Nama
Peserta 3=Paruh waktu 2=Kelas II, (Kary. Aktif) 1=WNI, No. Kartu Asuransi
2=WNA Asuransi
4=Penerima 3=Kelas III
Pensiun
20 21 22 23 24 25 26 27 28 29 30 31 32 33
No
Passport
34
JENIS PESERTA
]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]
TANGGAl REGISTRASI
NOMOR PKS
KODE PKS
MASA BERLAKU
KODE TANGGUNGAN
KODE KC
KODE DATI2
1 = Peserta
No No KK NIK/KITAS/KITAP Nama Lengkap 2 = Suami
4 = Anak
5 = Tambahan
1 2 3 4 5 6 7
1 1812020803110005 1812020906690003 M.TOSIM 2 WONOSOBO 06/09/1969
2 1812020803110005 1812026307710001 MARYATI 3 PANARAGAN 23/07/1971
3 1812020803110005 1812024604960003 SANTI APRIANA 4 MARGO MULYO 04/06/1996
4 1812020803110005 1812027009050004 ANISA ROMADIANA 4 MARGO MULYO 30/09/2003
5 1812020103118314 1812020202520001 KHADITS 2 JAWA TENGAH 02/02/1952
6 1812020103118314 1812024102670004 NGATINI 3 PURWODADI 02/01/1967
7 1812020103118314 1812022509770003 IMAM.S 4 BANDAR AGUNG 25/09/1977
8 1812020103118314 1812022008960001 SUHAIMI NURHIDAYATULLAH 4 DAYAMURNI 20/08/1996
9 1812020205120089 1812023112690006 RIYONO 2 JEMBER 31/12/1969
10 1812020205120089 1812027012740002 SUPINI 3 DAYAMURNI 30/12/1974
11 1812020205120089 1812024101000007 AEVALINIUM DWI RAMADANI 4 KOTA TENGAH 01/01/2000
12 1812020205120089 1812025804060003 ECHA SALWA SALASATUZ ZAHRO 4 KOTA TENGAH 18/04/2006
13 1812020501120036 1812022812730002 EDI SUPRAPTIN 2 BANDAR JAYA 25/12/1973
14 1812020501120036 1812024102740004 SITI ROMLAH 3 PULUNG KENCANA 02/01/1974
15 1812020501120036 1812025506970002 YUNITA ASIANI 4 DAYAMURNI 15/06/1997
16 1812020501120036 181202170205001 MUHAMAD IQBAL 4 DAYAMURNI 17/02/2005
17 1812022405110061 1812021501530001 WARAS 2 JEMBER 15/01/1953
18 1812022405110061 181225501570001 SUKATI 3 JEMBER 15/01/1957
19 1812022405110061 1812020512950001 DONI ANDI DESTIAWAN 4 DAYAMURNI 12/05/1995
20 1812022802115591 1812020104540003 KUSEN 2 JEMBER 04/01/1954
21 1812022802115591 1812024103600006 RASIYEM 3 JAWA TENGAH 03/06/1958
22 1812022802115591 1812022812000001 FAJAR ADI KRISTIAN 4 DAYAMURNI 20/01/2000
23 1812022802115591 1812020111030003 KRISTIAN YOSUA 4 DAYAMURNI 26/11/2002
24 1812020301120087 '1812021202720002 MULYADI 4 JEMBER 12/02/1972
25 1812020301120087 1812025505750005 SITI KHOTIMAH 2 DAYAMURNI 15/05/1975
26 1812020301120087 1812025408940003 SITI AMINAH 3 DAYAMURNI 14/08/1994
27 1812020301120087 1812021212000009 MUHAMMAD RISKI ANDREAN 4 JEMBER 12/12/2000
28 1812020301120087 1812021003100003 MUHAMMAD DIMAS ANDREAN 4 DAYAMURNI 10/3/2010
29 1812023010090002 1812020909924001 ADITIA SAPUTRA 1 DAYAMURNI 09/09/1992
30 1812022802113606 1812021508450001 KHAERONI 2 PURWOREJO 15/08/1945
31 1812022802113606 1812024505630007 MISTIK 3 MLOKO REJO 05/05/1963
32 1812022802113606 1812020304860005 RIBUT CHAIRULLAH 4 DAYAMURNI 03/04/1986
33 1812022802113606 1812026506890003 TUTIK LESTARI 4 DAYAMURNI 25/06/1989
34 1812022802113606 1812025212940007 RANI SATITI 4 DAYAMURNI 12/12/1994
35 1812020605120027 1812022102640003 MAT SLAMET 2 BANYUWANGI 21/04/1964
36 1812020605120027 1812027012720008 ALFIAH 3 JEMBER 30/12/1972
37 1812020605120027 1812021303940007 AGUNG FITRIONO 4 DAYAMURNI 06/06/1994
38 1812020605120027 1812021606960012 DIAN SAPUTRA 4 BANDAR AGUNG 18/08/1997
39 1812020605120027 1812021011020007 ROHMAN ARIF 4 DAYAMURNI 10/11/2002
40 1812021802100007 1812020711600001 TRIONO 2 LAMP SELATAN 07/11/1980
41 1812021802100007 1812024211640001 KATINAH 3 DAYAMURNI 02/11/1984
42 1812021802100007 1812024801070001 DIAJENG SITI AMALIA 4 DAYAMURNI 06/01/2007
43 1812021802100007 1812024108440001 M ISINI 5 JEMBER 01/08/1944
44 1812022105120030 1812022010600002 SURYADIN 2 JAWA BARAT 20/10/1960
45 1812022105120030 181202600970007 SRIYANI 3 JEMBER 20/09/1970
46 1812022105120030 1812025203920003 MUR YANTI 4 KOTA BUMI 12/03/1992
47 1812022105120030 1812024606060003 JENI 4 DAYAMURNI 06/06/2008
48 1812022105120030 1812024512420002 SUMINAH 5 JEMBER 05/12/1942
49 1812020203116329 181202047720005 BUYUH DKR 2 KARTA 04/07/1972
50 1812020203116329 1812025809860001 ENTI NOVIA 3 KARTA RAHARJA 18/09/1986
51 1812020203116329 1812026401050002 FEBRI LIA LESTARI 4 DAYAMURNI 24/01/2005
52 1812020204120009 1812021403730003 SOMADRI 2 KARTA 14/03/1973
53 1812020204120009 1812025805740003 YUSNAINI 3 KARTA 18/05/1974
54 1812020204120009 1812024306960006 BERTA DIAN PUTRI 4 MARGA KENCANA 03/06/1996
55 1812020204120009 1812022009020001 DANDI SETIA SAPUTRA 4 MARGA KENCANA 20/09/2002
56 181202221110045 1812026412130003 DESQILLA AYU PUTRI LUBI 1 MENGGALA 24/12/2013
57 1812020108120001 1812020304910003 TABRANI 2 ASTRA KSETRA 03/04/1991
58 1812020108120001 1812024602940005 FITRI NELIYANTII 3 MARGO MULYO 06/02/1994
59 1812020108120001 1812022101120002 MUHAMAD FARIZ 4 DAYAMURNI 21/01/2012
60 1812021008890008 181202100989008 ROHIMIN 2 GAJAH MATI 10/09/1989
61 181202590796005 1812025907560005 ASTUTI 3 DAYAMURNI 19/07/1996
62 1812020501120034 1812020706670009 ASEP SAEFUDIN 2 CIANJUR 07/06/1967
63 1812020501120034 1812024303690007 ATIN KARTINI 3 CIANJUR 03/03/1969
64 1812020501120034 1812020809920005 RENO SUSANTO 4 CIANJUR 08/09/1992
65 1812020501120034 1812020805000006 RENALDI 4 CIANJUR 08/05/2000
66 1812020501120034 1812022608060003 RENDI GUSTINO 4 DAYAMURNI 26/08/2006
67 1812022711140003 1812022202900003 KURNIA WIRAJAYA 2 DAYAMURNI 22/02/1990
68 1812022711140003 1803024501880007 PUTRI VINDI ARINI 3 KOTA BUMI 05/01/1988
69 1812022711140003 1812024409151025 ALDABELLA ULLIMA VIRAYZA 4 DAYAMURNI 04/09/2015
70 1812020803120026 1812025002650011 SITI JUARIYAH 1 METRO 10/02/1965
71 1812022105120039 1812020107440023 TUKIJAN 2 YOGYAKARTA 01/07/1944
72 1812022105120039 1812024601520005 SUPI KARISEM 3 YOGYAKARTA 06/01/1952
73 1812020103111237 1812022612640001 SUNARDI 2 BANTUL 26/12/1964
74 1812020103111237 1812024402690001 PARJIYEM 3 BANTUL 04/02/1969
75 1812020103111237 1812025606050002 NUR LISABELLA 4 DAYA ASRI 16/06/2005
76 1812020103111237 1812026604280001 JOYO SUMARTO 5 BANTUL 26/04/1928
77 1812021709130008 1812025503700008 SITI ROHIMAH 1 KOTA GAJAH 15/03/1970
78 1812021709130008 1812022007980001 BAGUS RIDHO SAPUTRA 4 DAYA MURNI 20/08/1998
79 1812021709130008 1812021502070003 MUHAMAD DIVA ALFAJAR 4 DAYA MURNI 15/02/2007
80 1812022808130019 1812020101750017 RAHMAT HIDAYAT 2 METRO 01/01/1975
81 1812022808130019 1812025003800006 SUMIYATI 3 MARGODADI 10/03/1980
82 1812022808130019 1812023101010006 IBNU FAJAR ALI 4 DAYA ASRI 31/01/2001
83 1812022808130019 1812024410050006 HESTI RAMADHANI 4 DAYA ASRI 04/10/2005
84 1812020903150011 1812021605780002 BISON SUMARWAN 2 KOTA GAJAH 16/05/1978
85 1812020903150011 1812027007820004 SITI YULIANA 3 REJO ASRI 30/07/1982
86 1812020903150011 1812025909150001 CESILIA AZZAHRA 4 DAYAMURNI 19/09/2015
87 1812021104120012 1812021005520010 SUGENG FAIZIN 2 KEBUMEN 10/05/1952
88 1812021104120012 1812024509560003 UMI SANGADAH 3 KEBUMEN 05/09/1956
89 1812021104120012 1812026610860005 NUR AFIKAH 4 DAYA MURNI 26/10/1986
90 1812021104120012 1812021910090001 NATAN ADNA HIMAWAN 5 KARTA RAHARJA 19/10/2009
91 1812021104120011 1812022810640002 TAHRIR AMIN 2 KEBUMEN 28/10/1964
92 1812021104120011 1812024910620005 UMI FARI'AH 3 KEBUMEN 09/10/1962
93 1812021104120011 1812020904990004 MUHAMMAD ARSYA RIFALDI 4 DAYA MURNI 09/04/1999
94 1812021006130023 1812020504590003 SUKARLAN 2 PATI 05/04/1959
95 1812021006130023 1812026508720003 RUMINAH 3 YOGYAKARTA 25/08/1972
96 1812021006130023 1812026611940003 WIDYA PANGESTU NINGRUM 4 DAYA MURNI 26/11/1994
97 1812021006130023 1812022305980002 RAHMAT AJI PANGESTU 4 DAYA MURNI 23/05/1996
98 1812020103114186 1812021710650001 IRZAL 2 KOTABUMI 17/10/1965
99 1812020103114186 1812024412700003 DESMAWATI 3 PADANG 04/12/1970
100 1812020103114186 1812024407920001 RIDA RAHMAWATI 4 DAYA MURNI 04/07/1992
101 1812020103114186 1812025206970004 RIZA RAHMAYUNI 4 DAYA MURNI 12/06/1997
102 1812020103114186 1812022709000001 ALFIN SEPTA ANANDA 4 DAYA MURNI 27/09/2000
103 1812022307120032 1812021603600001 AZWAR 2 PADANG 16/03/1960
104 1812022307120032 1812026512660006 BANI ATI 3 PADANG 25/12/1966
105 1812022307120032 1812020207870013 FATRONI 4 DAYA MURNI 02/07/1987
106 1812022307120032 1812025007890012 WESI LESNI 4 DAYA MURNI 10/07/1989
107 1812022307120032 1812025011910012 NIA FITRIANI 4 DAYA MURNI 10/11/1991
108 1812022307120032 1812022112980002 FAISAL RAMADAN 4 DAYA MURNI 20/12/1998
109 1812022603140005 1812021506880014 HAFIZ YUDHA PRASETYA 2 DAYA MURNI 15/06/1988
110 1812022603140005 1812025409900009 SUTARTI 3 MAKARTI 14/09/1990
111 1812022603140005 1812026101140001 CHALISTA AZ ZAHWA 4 SUMBER REJO 21/01/2014
112 1812021704120015 1812022607720006 BAMBANG IRAWAN 2 GEDUNG REJO 26/07/1972
113 1812021704120015 1812024512780001 HARNI 3 KESUMADADI 05/12/1978
114 1812021704120015 1812024512970001 IRANI DESRANIA PUTRI 4 DAYA MURNI 05/12/1997
115 1812021704120015 1812021205060002 BINTANG MUHAMMAD AKBAR 4 PULUNG KENCANA 12/05/2006
116 1812021704120015 1812022107110003 MUHAMMAD IRHAM ALFIANTO 4 DAYA ASRI 21/07/2011
117 1812021704120015 1812024107420028 SITI UMIATI 5 GADING REJO 01/07/1942
118 1812022902120041 1812021711710003 EKO GUNAWAN 2 METRO 17/11/1971
119 1812022902120041 1812025106760006 KASMI 3 DAYA MURNI 11/06/1976
120 1812022902120041 1812021903990003 YOGI RAHMAT GUNAWAN 4 DAYA MURNI 19/03/1999
121 1812022902120041 1812021707050001 M.NOPAL ASSIDIQ 4 DAYA MURNI 17/07/2005
122 1812020203111431 1812022007610002 SUGIMAN 2 JEMBER 20/07/1961
123 1812020203111431 1812024510700003 JUMIATI 3 JAWA TENGAH 05/10/1970
124 1812020203111431 1812026003010001 YULI YANTI 4 DAYA MURNI 20/03/2001
125 1812020203111431 1812026003060001 ELI YULIA SARI 4 DAYA MURNI 20/03/2006
126 1812020203111431 1812025901090001 SURANTI 4 DAYA MURNI 19/01/2009
127 1812020203111431 1812020901120001 FARHAN ADI SETIAWAN 4 DAYA MURNI 09/01/2012
128 1812022505110027 1812020101420004 KARTI MIHARJO 2 BANTUL 01/01/1942
129 1812022505110027 1812027110530002 SETIYATI 3 BANTUL 31/10/1953
130 1812022505110027 1812024101720009 MURWANTI 4 DAYA MURNI 01/01/1972
131 1812022505110027 1812021903780004 ISTANTORO 4 DAYA MURNI 19/03/1978
132 1812022505110027 1812022606810002 ISDIANTO 4 DAYA MURNI 26/06/1981
133 1812022505110027 1812021305850003 RACHMAD RUDI MULYADI 4 DAYA MURNI 13/05/1985
134 1812022505110027 1812026405930009 SRI SARWATI 4 DAYA MURNI 24/05/1993
135 1812021604120002 1812022412750003 PURWANTO 2 DAYA MURNI 24/12/1975
136 1812021604120002 1812024901820005 MAMI 3 GANTI WARNO 09/01/1982
137 1812021604120002 1812022210040002 SATYA PANDHU WIRAMADHAN 4 DAYA MURNI 22/10/2004
138 1812021604120002 1812022101160001 PRAMARTA KRISNA 4 CANDRA MUKTI 21/01/2016
139 1812021306120129 1812021008850008 AGUS PRIYANTO 2 BANDAR JAYA 10/08/1985
140 1812021306120129 1812026012920009 PRIYANTI 3 BANDAR SAKTI 20/12/1992
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639 1812021405120081 1812025007610001 KRISTIN YULIATUTIK 3 KOTA GAJAH 10/07/1961
640 1812021405120081 1812021004020003 HENDRIK ADI NUGROHO 4 GUNUNG TIMBUL 10/04/2002
641 1812020203112805 1812022610650003 TARIL 2 JAWA TENGAH 26/10/1965
642 1812020203112805 1812025107750001 SATIPAH 3 JEPARA 11/07/1975
643 1812020203112805 1812021412900001 SANTOSO 4 DAYASAKTI 14/12/1990
644 1812020203112805 1812022403960001 EDI PRAYETNO 4 DAYASAKTI 24/03/1996
645 1812020203112805 1812020512000002 AHMAD FAJAR 4 DAYASAKTI 05/12/2000
646 1812020203112805 1812020705060001 ANDRIYAN 4 GUNUNG TIMBUL 07/05/2006
647 1812021306120069 1812022906870001 PURWADI 2 PURWODADI 29/06/1987
648 1812021306120069 1812024306880002 SITI MAYSAROH 3 GUNUNG TIMBUL 03/06/1988
649 1812021306120069 1812022308090003 ALVINA RAMADANI 4 GUNUNG TIMBUL 23/08/2009
650 1812020107120020 1812020906850005 KURNIAWAN 2 JAWA TENGAH 09/06/1985
651 1812020107120020 1812026801860007 SITI RAHAYU 3 DAYASAKTI 28/01/1986
652 1812020107120020 1812027103120004 ALVINA FARIDATUS .S 4 GUNUNG TIMBUL 31/03/2012
653 1812021305120004 1812022001710005 MUHAMAD LEONG 2 JAKARTA 20/01/1971
654 1812021305120004 1812026009710004 KATIRAH 3 JEPARA 20/09/1971
655 1812021305120004 1812026212990008 RAHMA YANTI 4 KOTA BUMI 22/12/1999
656 1812021305120004 1812026711060004 HILDA LESTARI 4 BANDAR JAYA 27/11/2006
657 1812021007130017 1812022307820006 SUGIARTO 2 DAYASAKTI 23/07/1982
658 1812021007130017 1812024906920003 LINDA SARI 3 BANGUN SARI 09/06/1992
659 1812021007130017 1812022307120002 MUHAMMAD RAHMA DANI 4 BANGUN SARI 23/07/2012
660 1812021702150009 1812020502670003 SARNI 2 MADIUN 05/02/1957
661 1812021702150009 1812024707750011 YANTI 3 METRO 07/07/1975
662 1812021702150009 1812020702010001 MUHAMAD YANI 4 DAYASAKTI 07/02/2001
663 1812021702150009 1812020508070004 AGUS PRASETYO 4 GUNUNG TIMBUL 05/08/2007
664 1812021205120008 1812022903420001 PAITO 2 MALANG 29/03/1942
665 1812021205120008 1812026308270002 SAMIRAH 3 SUKABUMI 23/08/1947
666 1812021205120013 1812021507890005 SAI'IN 2 GUNUNG TIMBUL 15/07/1989
667 1812021205120013 1812024107890001 SILA AFILIA 3 MULYOASRI 01/07/1989
668 1812021205120013 1812025401140002 JANESA ARUMI AZZAHRA 4 GUNUNG TIMBUL 24/01/2014
669 1812021305120096 1812020709630010 IMAM 2 JEMBER 07/09/1963
670 1812021305120096 1812025006650016 TUMINI 3 JEMBER 10/06/1965
671 1812021305120096 1812021508830004 WAGINO 4 DAYASAKTI 15/08/1983
672 1812021305120096 1812021007970006 KOHIRIL 4 DAYASAKTI 10/07/1997
673 1812022411140034 1812022808850003 SISWADI 2 LAMPUNG UTARA 26/09/1985
674 1812022411140034 1812025510880002 SUPRIHATIN 3 SIDO MAKMUR 15/10/1988
675 1812022411140034 1812024803100003 INES SANTIKA 4 SUKANANTI 05/03/2010
676 1812021702150011 1812021605970004 KADIS 2 BLITAR 16/09/1957
677 1812021702150011 1812025507560001 WARSIH 3 JEPARA 15/07/1956
678 1812021302120008 1812022607760001 SUKIRNO 2 BANYUMAS 26/07/1976
679 1812021302120008 1812024108850006 SULASTRI 3 DAYASAKTI 01/08/1985
680 1812021302120008 1812020802110002 YONATAN MOSES P. 4 GUNUNG TIMBUL 08/02/2011
681 1812020107120026 1812021206800008 PURNOMO 2 DAYASAKTI 12/06/1980
682 1812020107120026 1812025411910002 PUJI LESTARI 3 DAYASAKTI 14/11/1991
683 1812020107120026 1812024707130003 PUTRI RAHAYU 4 DAYASAKTI 07/07/2013
684 1812021305120070 1812021910240001 ROHMAD 2 BOJO NEGORO 19/10/1934
685 1812021305120070 1812024812360001 SUYATI 3 JEPARA 08/12/1936
686 1812021305120070 1812020406990002 SUPRAYITNO 4 DAYASAKTI 04/06/1999
687 1812020107120027 1812021512300002 TOKED 2 JEMBER 15/12/1930
688 1812020107120027 1812025601420002 MUINAH 3 JEMBER 16/01/1942
689 1812021405120011 1812020306760003 ISHAK 2 KARTA 03/06/1976
690 1812021405120011 1812025009770010 LINA WATI 3 KARTA 10/09/1977
691 1812021405120011 1812021205010003 ANDIKA JAYA SUTRA 4 GUNUNG TIMBUL 12/05/2001
692 1812021405120011 1812020704060006 AGENG PRAYOGA 4 GUNUNG TIMBUL 07/04/2006
693 1812021405120011 1812025010100001 OKTA NOVIA SARI 4 GUNUNG TIMBUL 10/10/2010
694 1812021405120011 1812025903530002 HALIMAH 5 KARTA 19/03/1953
695 1812020701100035 1812021006730001 LASIO UNTUNG 2 DAYASAKTI 10/06/1967
696 1812020701100035 1812024802820001 NUR SUCIATI 3 DAYASAKTI 08/02/1982
697 1812020701100035 1812026702970001 FITRIA RAMADANI 4 BENGKULU SEL. 27/02/1997
698 1812020701100035 1812026005060001 MEGA TRI WAHYUNI 4 GUNUNG TIMBUL 20/05/2008
699 1812020705120060 1812020712670001 MUSLIM 2 JEMBER 07/12/1967
700 1812020705120060 1812025301720005 SITI KOMSATUN 3 JEMBER 13/01/1972
701 1812020705120060 1812022106990004 MUHAMAD JAMRONI 4 DAYASAKTI 21/08/1999
702 1812020705120060 1812020708020008 ALFAN SALIM 4 GUNUNG TIMBUL 07/06/2002
703 1812021605160005 1812021803920004 MUHAMAD JALIL 2 LAMPUNG UTARA 18/03/1992
704 1812021605160005 1812024706940006 WAHYU RETNO SAVITRI 3 JAJARAN BARU 07/06/1994
705 1812021605160005 1812025812100002 RISKA DWI ARYANTI 4 JAJARAN BARU 18/12/2010
706 1812020702120023 1812025102690003 WAGINEM 1 JEMBER 11/02/1969
707 1812020702120023 1812024206870004 RUKATI 4 DAYASAKTI 02/06/1987
708 1812020701100033 1812021505790001 HARIYANTO 2 WAY SIDO 15/05/1979
709 1812020701100033 1812026505850001 WARSIYEM 3 DAYASAKTI 25/05/1985
710 1812020701100033 1812025506050001 ANGGRAENI 4 GUNUNG TIMBUL 15/06/2005
711 1812021001120049 1812022008650005 SUKARNO 2 JEMBER 20/08/1965
712 1812021001120049 1812025811680002 KOMSIAH 3 JEMBER 18/11/1968
713 1812021001120049 1812020303890003 SAHRUDI 4 DAYASAKTI 03/03/1989
714 1812021001120049 1812025002990004 LINA ANIS SANTIKA 4 DAYASAKTI 10/02/1999
715 1812021001120049 1812020802000005 SEFI ALDIANSYAH 4 DAYASAKTI 08/02/2000
716 1812021702150010 1812022605880006 PUJO 2 BOJO NEGORO 26/05/1988
717 1812021702150010 1812026706950001 RISKA MUSTIKA SAFITRI 3 GUNUNG TIMBUL 27/06/1995
718 1812021702150010 1812024109150001 ANISA MUALIMAH 4 DAYAMURNI 01/09/205
719 1812021505120065 1812020704850005 SURYANTO 2 MESUJI 07/04/1985
720 1812021505120065 1812026012880006 YULIANA 3 DAYASAKTI 20/12/1988
721 1812021505120065 1812021801080001 AHMAD PRAYOGA G. 4 GUNUNG TIMBUL 18/01/2008
722 1812020410100010 1812022009750001 NARNO 2 METRO 20/09/1975
723 1812020410100010 1812026907890001 SITI ISTIKOMAH 3 DAYASAKTI 29/07/1989
724 1812020410100010 1812024212090001 DITA DESTIANTI 4 GUNUNG TIMBUL 02/12/2009
725 1812021305120092 1812020501740003 SUNARYO 2 KARTARAHARJA 05/01/1974
726 1812021305120092 1812025007770004 SUTRI ANINGSIH 3 METRO 10/07/1977
727 1812021305120092 1812021611980004 YUDI SAPUTRA 4 DAYASAKTI 16/11/1998
728 1812021305120092 1812020601040001 TAUFIK HIDAYAT 4 DAYASAKTI 06/01/2004
729 1812021805110001 1812023112410001 KUSNAN 2 JEMBER 31/12/1941
730 1812021805110001 1812026611590001 NGADIYAH 3 JEMBER 26/11/1959
731 1812021305120016 1812022006730002 PENDI 2 KOTA GAJAH 20/05/1973
732 1812021305120016 1812024101730008 PURWANTI 3 METRO 01/01/1973
733 1812021305120016 1812024101970011 ARITA PUTRI AFRIANI 4 GUNUNG TIMBUL 01/01/1997
734 1812021305120016 1812022909040004 SEVIAN ARTYA AUDI P. 4 GUNUNG TIMBUL 29/09/2004
735 1812021305120049 1812021410780006 YETNOTO 2 PULUNG KENCANA 14/10/1978
736 1812021305120049 1812025208810010 SITI MAUMANAH 3 DAYASAKTI 12/08/1981
737 1812021305120049 1812020809000006 M.FAUJI 4 DAYASAKTI 08/09/2000
738 1812021305120049 1812020305020006 ANGGA 4 PULUNG KENCANA 03/05/2002
739 1812021305120049 1812026510890001 ANGGUN NUR HIDAYAH 4 GUNUNG TIMBUL 25/10/2009
740 1812021203120011 1812022301880004 TUNGGUL ADI .W 2 KOTA BUMI 23/01/1988
741 1812021203120011 1812026209920006 MUJARO'AH 3 DAYASAKTI 22/09/1992
742 1812021203120011 1812026203120003 MAFAZHA NABILAATUN H. 4 GUNUNG TIMBUL 22/05/2012
743 1812021205120050 1812025706640004 SURTI 1 JEMBER 17/06/1984
744 1812021205120050 1812020905870003 USNUL YAKIN 4 DAYASAKTI 09/05/1987
745 1812021205120020 1812024407570004 SITI MASAMAH 1 JEMBER 04/07/1957
746 1812021205120020 1812024604960004 SITI SUMARTI 4 GUNUNG TIMBUL 06/04/1996
747 1812022802116716 1812022809760002 SURAJIMAN 2 MARGA KENCANA 26/09/1976
748 1812022802116716 1812025709870001 SITI KHOIRIYAH 3 DAYASAKTI 27/08/1987
749 1812022802116716 1812025610040001 FITRIA W.RAMADANI 4 GUNUNG TIMBUL 16/10/2004
750 1812022802116716 1812020509140001 WILDAN KHOIRUN N. 4 GUNUNG TIMBUL 05/09/2014
751 1812022802117366 1812021307730001 JAMALUDIN 2 PUGUNG RAHARJA 13/07/1973
752 1812022802117366 1812024808810007 SUNGINYATI 3 DAYASAKTI 08/08/1981
753 1812022802117366 1812024109970001 RENILA ALFI MAGHFIROH.J 4 DAYASAKTI 01/09/1997
754 1812022802117366 1812025806110001 CAHYA CINTA AL AZWA P. 4 GUNUNG TIMBUL 18/06/2011
755 1812021205120030 1812020112250003 SAJAM '2 BOJO NEGORO 01/02/1925
756 1812021205120030 1812024810450003 MARSIH 3 BOJO NEGORO 08/10/1945
757 1812021205120030 1812020602860003 SUTOWO 4 BOJO NEGORO 06/02/1986
758 1812021205120030 1812022605880002 PUJO 4 BOJO NEGORO 28/05/1988
759 1812021302120012 1812026008580001 TARMINI 1 JEMBER 20/08/1956
760 1812021705120047 1812022303720003 YASRO HIDAYAT 2 JEPARA 23/03/1972
761 1812021705120047 1812025204780006 NGATIYEM 3 DAYASAKTI 12/04/1978
762 1812021705120047 1812022911940004 IRFAN SOFIANTO 4 KARTARAHARJA 29/11/1994
763 1812021705120047 1812022505019007 AHMAD FAJRI SOFIANTO 4 DAYASAKTI 25/05/2001
764 1812021705120047 1812020302050002 ALDI SETIAWAN 4 GUNUNG TIMBUL 03/02/2005
765 1812021305120097 1812021203650008 SUJONO 2 MALANG 12/03/1965
766 1812021305120097 1812025205630005 SUCIARI 3 MALANG 12/05/1963
767 1812021305120097 1812020402970005 PEBRI PRASTYO 4 DAYASAKTI 04/02/1997
768 1812021305120097 1812020810000004 TOMI ANDREAS 4 DAYASAKTI 08/10/2000
769 1812021305120097 1820286050800002 GRESIA NANDA LESTARI 4 GUNUNG TIMBUL 26/06/2008
770 1812020102120005 1812022008910009 MUHAMMAD ARIFIN 2 DAYASAKTI 20/08/1991
771 1812020102120005 1812025010930006 TRI UTAMI 3 MAKARTI 10/10/1993
772 1812020102120005 1812026302120001 NADILAH GAYVANY 4 GUNUNG TIMBUL 23/02/2012
773 1812021502100027 1812022607540001 KARLI 2 JEMBER 26/07/1954
774 1812021502100027 1812026006450001 DARMI 3 JEMBER 20/06/1945
775 1812021502100027 1812021501870001 M.JAINURI 4 JEMBER 15/01/1987
776 1812021502100027 1812024508880001 JAENAB 4 JEMBER 05/08/1988
777 1812021502100027 1812021808900001 JAENAL ABIDIN 4 JEMBER 18/08/1990
778 1812021502100027 1812025012050001 DESI AMALIA PUTRI 4 GUNUNG TIMBUL 10/12/2005
779 1812022506120039 1812020707760008 MAT JAELANI 2 PUGUNG 07/07/1976
780 1812022506120039 1812025611860006 UMI KHASANAH 3 DAYASAKTI 15/11/1988
781 1812022506120039 1812022409040006 MUHAMMAD ILHAM A. 4 GUNUNG TIMBUL 24/09/2004
782 1812022506120039 1812025107140002 KESYA LAURA NINGRUM 4 GUNUNG TIMBUL 11/07/2014
783 1812021507130010 1812021412300002 NASIRIN 2 JEMBER 14/02/1930
784 1812021507130010 1812026108470002 SITI PHOTIJAH 3 JEMBER 21/08/1947
785 1812021205120009 1812021910640001 MARSOM 2 JEMBER 19/10/1964
786 1812021205120009 1812025006670005 KATINEM 3 PRINGSEWU 10/06/1967
787 1812021205120009 1812022310910002 DUWIK MARJUKI 4 GUNUNG MADU 23/10/1991
788 1812021205120009 1812024101960006 NOR KOMALA 4 DAYASAKTI 01/01/1996
789 1812021205120009 1812026608000005 PATMA ASIH 4 DAYASAKTI 26/09/2000
790 1812021205120009 1812024202370003 MARSINI 5 BLITAR 02/03/1937
791 1812021205120028 1812021004550005 SUMARNO 2 PURWODADI 10/04/1955
792 1812021205120028 1812025507570005 SITI AMINAH 3 JEMBER 15/07/1957
793 1812021008100014 1812020409600001 JUMANGIN 2 BANYUWANGI 04/09/1960
794 1812021008100014 1812024712720001 SUMIATI 3 DAYASAKTI 07/12/1972
795 1812021008100014 1812020912000001 HANAN NURHUDA 4 DAYASAKTI 09/12/2000
796 1812021008100014 1812021002240001 JAJULI 5 JEMBER 10/02/1924
797 1812021709120020 1812021208800013 AGUNG PRANOTO 2 SUKARAJA N. 12/08/1986
798 1812021709120020 1812024409900004 WIJI ASTUTI 3 DAYASAKTI 04/09/1990
799 1812021709120020 1812022001070004 AAN SAPUTRA 4 GUNUNG TIMBUL 20/01/2007
800 1812022802117376 1812020408590002 AGUS SUWITO 2 JEMBER 04/08/1959
801 1812022802117376 1812024902670001 SITI SUKARSIH 3 JEMBER 09/02/1967
802 1812022802117376 1812021703850004 AGUS SANTOSO 4 LAMPUNG 17/03/1985
803 1812022802117376 1812020510920001 ANDI ARISMANATA 4 DAYASAKTI 05/01/1992
804 1812022802117376 1812020705950002 MASDA SUSILA 4 DAYASAKTI 07/06/1995
805 1812022802117376 1812021905050001 DENI SAPUTRA 4 GUNUNG TIMBUL 19/05/2005
806 1812022802117376 1812021305100001 DIMAS IRAMAULANA 4 GUNUNG TIMBUL 13/05/2010
807 1812020808120019 1812020808800013 SUJARWANTO 2 METRO 08/08/1980
808 1812020808120019 1812026002820003 TUMINI 3 DAYASAKTI 02/02/1982
809 1812020808120019 1812022002030003 YAHAYA AMIRUL AJID 4 GUNUNG TIMBUL 20/02/2003
810 1812020808120019 1812020410070001 ANGGI RAMADANI 4 GUNUNG TIMBUL 04/10/2007
811 1812020808120019 1812022701120001 DIKI APRILIYANA 4 GUNUNG TIMBUL 27/01/2012
812 1812021305120110 1812020204850004 SUTIKNO 2 LAMPUNG TENGAH 02/04/1985
813 1812021305120110 1812025505890009 JUWARNI 3 DAYASAKTI 15/05/1989
814 1812021305120110 1812022111080001 VINO ALDI FAHROJI 4 GUNUNG TIMBUL 21/11/2008
815 1812020701100053 1812022605490001 SUMARTO 2 JEPARA 26/05/1949
816 1812020701100053 1812025309600001 SUKATI 3 PONOROGO 13/09/1960
817 1812020701100053 1812025809990001 SINTA NURIYAH 4 RIAU 18/09/1999
818 1812020701100053 1812020506010001 MUHAMMAD ERPAN 4 RIAU 05/06/2001
819 1812020402140037 1812022101710003 JUNAIDI 2 PALEMBANG 21/01/1971
820 1812020402140037 1812025809750005 SITI FATIMAH 3 TANJUNG RATU 18/09/1975
821 1812020402140037 1812025308980007 JUSI ALDESKA 4 MARGA KENCANA 13/08/1996
822 1812020402140037 1812021700888007 LEO SAPUTRA 4 DAYAMURNI 17/08/1998
823 1812020402140037 1812020505010008 CANDRA KURNIA 4 GUNUNG TIMBUL 05/05/2002
824 1812020402140037 1812024505030005 MELA PERTIWI 4 GUNUNG TIMBUL 05/05/2003
825 1812020706110025 1812023112610002 JAURI 2 MALANG 31/12/1961
826 1812020706110025 1812024605650008 SUMARI 3 KOTA GAJAH 06/05/1965
827 1812020706110025 1812025707910007 BETIK YULIANDARI 4 DAYASAKTI 17/07/1991
828 1812020706110025 1812020107950070 YULIUS TRI HANDOKO 4 DAYASAKTI 01/07/1995
829 1812020706110025 1812022912050003 DANIEL KRISTIANTO 4 GUNUNG TIMBUL 29/12/2005
830 1812020103118257 1812021206300001 TUKIJAN 2 JEMBER 12/06/1930
831 1812020103118257 1812025405470002 SARENGAH 3 JEMBER 14/05/1947
832 1812020605130019 1812025810550002 MARIYATI 1 JEMBER 18/10/1955
833 1812020605130019 1812020604940005 MATIUS KRISDIANTO 4 MESUJI 06/04/1994
834 1812020605130019 1812025508950005 YULIANA 4 MESUJI 15/08/1995
835 1812020605130019 1812024107020040 JUMIYATI 5 TULUNG NYUBUK 01/07/2002
836 1812020604120027 1812020808680011 WIYONO 2 MALANG 08/08/1968
837 1812020604120027 1812024812700007 WARINI 3 MALANG 08/12/1970
838 1812020604120027 1812022910010004 ROBI ARI OKTOVINO D. 4 BOGOR 29/10/2001
839 1812020604120027 1812026204040002 APRI PUTRI MELATI 4 GUNUNG TIMBUL 22/04/2004
840 1812020604120027 1812021408060006 TEPEN PUTRA BAYU A. 4 GUNUNG TIMBUL 14/09/2006
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844 1812020701100046 1812025511950001 ISNARTA 4 BENGKULU 15/11/1995
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846 1812020701100046 1812022712000001 ROBI HENGKI SETIAWAN 4 GUNUNG TIMBUL 27/12/2007
847 1812020706120065 1812022004480001 RIMANTO 2 METRO 20/04/1948
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850 1812020706120065 1812020705880004 RONI ERDIANTO 4 METRO 07/05/1988
851 1812021712120002 1812022604900003 ZAINAL ARIFIN 2 DAYASAKTI 26/04/1990
852 1812021712120002 1812024609200002 SUNARTI 3 MULYA KENCANA 06/06/1992
853 1812021712120002 1812023108120001 AAR UMAR MANSYUR 4 GUNUNG TIMBUL 31/08/2012
854 1812021502100011 1812020504500001 SUPARNI HADI 2 JEPARA 05/04/1950
855 1812021502100011 1812027012550001 SITI KOLIFAH 3 KEBUMEN 30/12/1955
856 1812021605120124 1812020604700006 KASIANTO 2 JEMBER 06/04/1970
857 1812021605120124 1812024611770004 NUR HIDAYAH 3 DAYASAKTI 06/11/1977
858 1812021605120124 1812021106000006 BAYU HIDIANTARA 4 DAYASAKTI 11/06/2000
859 1812021003140013 1812021707850006 WAYASDI 2 CANDRA KENCANA 17/07/1985
860 1812021003140013 1812024809880006 SETIA WATI 3 DAYASAKTI 08/09/1988
861 1812021003140013 1812026911110001 MELATI NOVITA SARI 4 CANDRA KENCANA 29/11/2011
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868 1812021806120038 1812026404920003 ANITA 3 GUNUNG MENANTI 24/04/1992
869 1812022411110018 1812021102520003 YUSUF 2 GUNUNG BATIN 11/02/1952
870 1812022411110018 1812025010670004 DEWI 3 GUNUNG BATIN 10/10/1967
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875 1812021710120002 1812021502910004 RUDI YANTO 2 MARGO MULYO 15/02/1991
876 1812021710120002 1812025501910006 SRI YANTI 3 GUNUNG MENANTI 15/01/1991
877 1812021710120002 1812024602130003 AISYA FITRIYANI 4 MARGO DADI 06/02/2013
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880 1812021607120007 1812022408890002 TONI 4 MARGO MULYO 24/08/1989
881 1812021607120007 1812025002920005 RIDA 4 MARGO MULYO 10/02/1992
882 1812020506120156 1812020703870003 ADI SOFYAN 2 DAYA MURNI 07/03/1987
883 1812020506120156 1812024909890005 ROSNA WATI 3 GUNUNG KRAMAT 09/09/1989
884 1812020506120156 1812024303110003 RAYA AZ'ZAHRA 4 MARGODADI 03/03/2011
885 1812020203116381 1812021010880012 RUSDI BIN ASAL 2 MARGO MULYO 10/10/1988
886 1812020203116381 1812024701890003 YENI WATI 3 GUNUNG KRAMAT 07/01/1989
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1367 1812012704120018 1812010701800005 EFRI ZAINURI 2 PANARAGAN 07/01/1980
1368 1812012704120018 1812016004830004 NELY YANTI 3 KOTA BUMI 20/04/1983
1369 1812012704120018 1812011202090003 THORIQ JUANZ ALZA IQBAL 4 PANARAGAN 12/02/2009
1370 1812030601120013 1812030204680003 HAMSYAH 2 KARTA 02/04/1968
1371 1812030601120013 1812034408720002 KARNILA 3 KARTA 04/08/1972
1372 1812030601120013 1812032706970002 HERWANSYAH 4 KARTA 27/06/1997
1373 1812030601120013 1812036704030005 HENNY HENDRI YANTI 4 KARTA 27/04/2003
1374 1812032307130001 1812030107850098 SADRI 2 KARTA 01/07/1985
1375 1812032307130001 1812034707890005 YULI YANA 3 KARTA 07/07/1989
1376 1812032307130001 1812030409100001 YANDA SAPUTRA PRATAMA 4 KARTA 04/09/2010
1377 1812030601120014 1812031312750004 BASYUNI 2 KARTA 13/12/1975
1378 1812030601120014 1812034401770004 LENI 3 KARTA 04/01/1977
1379 1812030601120014 1812030510980003 REDHO FIRMANSYAH 4 KARTA 05/10/1998
1380 1812030601120014 1812031005010003 RESKI ARDIANSYAH 4 KARTA 10/05/2001
1381 1812030601120014 1812031908060003 RENTA SAPUTRA JAYA 4 KARTA 19/08/2006
1382 1812030301130001 1812030107790028 HELMI YASI 2 KARTA 01/07/1979
1383 1812030301130001 1812036206750003 PARINA WATI 3 KARTA KARYA 22/08/1975
1384 1812030301130001 1812034309090001 HERGRA RIZKI PURNAMA 4 KARTA RAHARJA 03/09/2009
1385 1812030301130001 1812034112120003 HELEN NABILA PUTRI 4 KARTA RAHARJA 01/12/2012
1386 1812032203110015 1812032304800002 HERPANI 2 KARTA 23/04/1980
1387 1812032203110015 1812035805790001 INTAN SARI 3 LOPANG TENGAH 18/05/1979
1388 1812032203110015 1812034108060002 PAZA TRI UTAMI 4 KOTABUMI 01/08/2006
1389 1812033006150005 1812030306910005 JONI SAPUTRA 2 KARTA 03/06/1991
1390 1812033006150005 1812015802940005 ERYATI 3 MENGGALA MAS 16/02/1994
1391 1812031401160002 1812030505710001 BAHRUM 2 KARTA 05/08/1971
1392 1812031401160002 1812034510750001 ROSMALIA 3 KARTA 05/10/1975
1393 1812031401160002 1812035212970010 ANTIKA DESTA ROBA 4 KARTA 12/12/1997
1394 1812031401160002 1812032411000004 ROBI NOVANDA ROBA 4 KARTA 24/11/2000
1395 1812031401160002 1812032809040004 TRI PANCA SEPTI ROBA 4 KARTA 28/09/2004
1396 1812031401160002 1812036304070005 CICI APRISA ROBA 4 KARTA 23/04/2007
1397 1812031908110018 1812032003680003 UMAR SYAH 2 KARTA 20/03/1968
1398 1812031908110018 1812034402690002 SAIMAH 3 KARTA 04/02/1969
1399 1812031908110018 1812034709970001 EKA SEPTIANA 4 KARTA 09/09/1997
1400 1812031908110018 1812031210040001 KIKI PAREL 4 KARTA 16/10/2004
1401 1812030506130001 1812032906720003 SAIDAL 2 KARTA 29/06/1972
1402 1812030506130001 1812034611750003 NUR LINA 3 KARTA 06/11/1975
1403 1812030506130001 1812031202950008 PAIDO ROYMONDO 4 KARTA 12/02/1995
1404 1812030506130001 1812036811020002 NUSA MUTIARA 4 KARTA 28/11/2002
1405 1812032110130010 1812031812380001 TURUNAN ARIP 2 KARTA 18/12/1938
1406 1812032110130010 1812034107470029 MARYATI 3 KARTA 01/07/1947
1407 1812032110130010 1812034410860001 YUSTINA IRAWAN 4 KARTA 04/10/1986
1408 1812031508110003 1812035403650001 SUWATI 1 KARTA 14/03/1965
1409 1812031508110003 1812030911880004 ARIANTO 4 KARTA 09/11/1988
1410 1812031508110003 1812030906920006 ADI SANJAYA 4 KARTA 09/06/1992
1411 1812031508110003 1812031008000001 BUYUNG AHMAD 4 KARTA 10/08/2000
1412 1812030610150011 1812031706822003 SUKAMTO 2 MARGA KENCONO 17/08/1982
1413 1812030610150011 1812036710820004 RIRIN ANDRIANI 3 KUNINGAN 27/10/1982
1414 1812030610150011 1812030206040005 OVAL JATI PRATAMA 4 MARGA KENCONO 02/08/2004
1415 1812030610150011 1812033004100003 KEVIN QOLBI AFFANSYAH 4 MARGA KENCONO 30/04/2010
1416 1812012601120091 1812011208650005 PARSIANTO 2 MALANG 12/08/1965
1417 1812012601120091 1812015006850017 SUKARTI 3 MALANG 10/06/1965
1418 1812012601120091 1812016201930006 NURAINI 4 PULUNG KENCANA 22/01/1993
1419 1812012601120091 1812012504960006 FERI PRANATA 4 PULUNG KENCANA 25/01/1996
1420 1812012601120091 1812016504980008 DEVI APRILIA 4 PULUNG KENCANA 25/04/1998
1421 1812012601120091 1812012801060001 FERNANDO 4 PULUNG KENCANA 28/01/2006
1422 1812012601120091 1812014107350039 SAMIJAH 5 MALANG 01/07/1935
1423 1812012908120008 1812012606840010 SULIYONO 1 PULUNG KENCANA 26/06/1984
1424 1812012908120008 1812015312040005 RIA LESTARIANA 4 PULUNG KENCANA 13/12/2004
1425 1812012905120037 1812012107830005 ROMLAN 2 TRIMO DADI 21/07/1983
1426 1812012905120037 1812015805820003 ENI PURNAWATI 3 METRO 18/05/1982
1427 1812012905120037 1812010803090003 EFAN BIMBO PRATAMA 4 PULUNG KENCANA 09/03/2009
1428 1812012905120037 1812010809150001 KYOSHI MAULANA RAMADHAN 4 PULUNG KENCANA 15/09/2012
1429 1812012905120037 1812010809150001 DANISH DANIAL AZKA 4 TULANG BAWANG BARAT 08/09/2015
1430 1812012602118579 1812011006750001 SUTRISNO 2 BANDAR JAYA 10/06/1975
1431 1812012602118579 1812015503780001 TUMINEM 3 METRO 15/03/1978
1432 1812012602118579 1812016004000001 DEWI NUR ROHMAH 4 CANDRA KENCANA 20/04/2000
1433 1812012602118579 1812010101090001 MUHAMMAD JAUZA RAFID 4 CANDRA KENCANA 01/01/2009
1434 1812011806120069 1812011008770022 BAMBANG SANTOSO 2 CANDRA KENCANA 10/08/1977
1435 1812011806120069 1812015007830011 FEMI FESNIATI 3 BLITANG 10/07/1983
1436 1812011806120069 1812012006100001 EGIE WAHYU PRADANA 4 CANDRA KENCANA 20/06/2010
Jenis Status
Kelamin Kawin
Kode
0=TD Kode Desa Kode
Alamat Tempat Tinggal RT RW Kecamatan Nama Kecamatan Nama Desa
1=L 1=B, (diisi petugas) Faskes Tk.I
(diisi petugas)
2=P 2=K,
3=C
8 9 10 11 12 13 14 15 16 17 18
1 2 DAYA MURNI 003 002 TUMIJAJAR DAYA MURNI
1 2 DAYA ASRI 005 001 TUMIJAJAR DAYA ASRI
1 2 MURNI JAYA 01 01 TUMIJAJAR MURNI JAYA
1 2 DAYA SAKTI 008 003 TUMIJAJAR DAYA SAKTI
1 2 GUNUNG TIMBUL 09 04 TUMIJAJAR GUNUNG TIMBUL
2' 1 GUNUNG TIMBUL 08 04 TUMIJAJAR GUNUNG TIMBUL
2' 1 GUNUNG TIMBUL 07 03 TUMIJAJAR GUNUNG TIMBUL
1 2 MARGO DADI 15 06 TUMIJAJAR MARGO DADI
2 2 MARGODADI 013 006 TUMIJAJAR MARGODADI
1 2 MARGO MULYO 011 003 TUMIJAJAR MARGO MULYO
1 2 SUMBER REJO 001 001 TUMIJAJAR SUMBER REJO
1 2 GUNUNG MENANTI 14 05 TUMIJAJAR GUNUNG MENANTI
1 2 GEDUNG RATU 001 005 TULANG BAWANG UDIK GEDUNG RATU
2 2 MARGA KENCANA 024 005 TULANG BAWANG UDIK MARGA KENCANA
1` 2 MARGA KENCANA 010 002 TULANG BAWANG UDIK MARGA KENCANA
1 2 KARTA SARI 07 TULANG BAWANG UDIK KARTA SARI
1 2 KARTA SARI 16 04 TULANG BAWANG UDIK KARTA SARI
1 2 KARTA RAHARJA 07 08 TULANG BAWANG UDIK KARTA RAHARJA
1 2 MULYO ASRI 04 03 TULANG BAWANG TENGAH MULYO ASRI
1 2 MULYA ASRI 03 03 TULANG BAWANG TENGAH MULYA ASRI
1 2 MULYA JAYA 23 05 TULANG BAWANG TENGAH MULYA JAYA
1 2 MULYO KENCONO 01 05 TULANG BAWANG TENGAH MULYO KENCONO
1 2 PANARAGAN 01 07 TULANG BAWANG TENGAH PANARAGAN
1 2 PENUMANGAN 01 04 TULANG BAWANG TENGAH PENUMANGAN
1 2 PANARAGAN JAYA 01 06 TULANG BAWANG TENGAH PANARAGAN JAYA
1 2 WAY SIDO 03 01 TULANG BAWANG UDIK WAY SIDO
1 2 KARTA 04 08 TULANG BAWANG UDIK KARTA
1 2 KARTA 08 TULANG BAWANG UDIK KARTA
1 2 MARGA KENCONO 06 02 TULANG BAWANG UDIK MARGA KENCONO
1 2 PULUNG KENCANA' 04 05 TULANG BAWANG TENGAH PULUNG KENCANA'
1 2 CANDRA KENCANA 002 001 TULANG BAWANG TENGAH CANDRA KENCANA
Status Kelas Rawat Kewarga
Negaraan
Nama Faskes Tk.I Faskes Telepon Email NIP Jabatan 2=Kontrak, 1=Kelas I, Tunj. Tetap
Dokter Gigi Dokter Gigi (Kary. Aktif)
Peserta 3=Paruh waktu 2=Kelas II, (Kary. Aktif) 1=WNI,
4=Penerima 3=Kelas III 2=WNA
Pensiun
19 20 21 22 23 24 25 26 27 28 29 30
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Asuransi Lainnya
No
No. NPWP Passport
Nama
No. Kartu Asuransi Asuransi
31 32 33 34

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