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| LEMBAR DISPOSISI |
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| No. Indeks |
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| Tgl. Terima |
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| Sifat surat |
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Rahasia |
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Penting |
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Biasa |
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| Kode |
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Tgl. Penyelesaian : |
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| Tanggal |
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| Nomor |
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| Asal |
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| Isi Surat/ |
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| Perihal |
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| Instruksi
dan Informasi : |
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| Diteruskan
Kepada |
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2 |
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3 |
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4 |
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…...………………………………………………… |
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| Isi |
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….…………………………………………………………………………. |
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| Sesudah
digunakan harap segera dikembalikan |
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| Kepada |
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| Tanggal |
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