Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

SURAT PERNYATAAN
Yang membuat pernyataan dibawah ini :
:
:
:
:
:
:
:

Nama
Tempat, tgl. lahir
Jenis Kelamin
Agama
Pekerjaan
Alamat
No. KTP

.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................

Dengan ini menyatakan dengan sebenarnya bahwa :

Nama : ...........................................................................................................................................................
yang ada di Buku Nikah No. ...................................................................................................
Nama : ...........................................................................................................................................................
yang ada di KTP No. .....................................................................................................................................
Nama : ...........................................................................................................................................................
yang ada di KK No. .......................................................................................................................................
Nama : ...........................................................................................................................................................
yang ada di Ijazah No. ..........................................................................................................................
Nama : ...........................................................................................................................................................
yang ada di Surat Kelahiran No. .....................................................................................
adalah satu orang.
Adapun yang dipergunakan dalam Akta / Kutipan Akta Kelahiran ialah
Nama : ....................................................................................................................................................... yang ada di ...................................................................................................................................................................
Untuk menguatkan penyataan yang saya buat, saya sertakan para saksi yang mengetahui
nama-nama tersebut.
Demikian Surat pernyataan ini saya buat dengan sebenarnya dan apabila dikemudian hari
pernyataan saya ini tidak sesuai/tidak benar saya berikut para saksi bertanggung jawab terhadap
semua akibat hukum yang timbul, tidak akan melibatkan Pejabat yang ikut menanda tangani
pernyataan ini dan kami sanggup dituntut dihadapan hakim sesuai dengan hukum yang berlaku.

Madiun, .........................................................................................
Yang menyatakan
Saksi I
Nama
Umur
Pekerjaan
Alamat

(materai
Rp. 6000,00,-)

:
:
:
:

.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

Tanda tangan
Saksi II
Nama
Umur
Pekerjaan
Alamat

___________________________________________

Mengetahui,
Kepala Ds./Kel. ..............................................................

.......................................................................................................................................

___________________________________________

:
:
:
:

.......................................................................................................................................

.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

Mengetahui,
Kepala KUA Kec. Dolopo

Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

SURAT PERNYATAAN
Yang membuat pernyataan dibawah ini :
:
:
:
:
:
:
:

Nama
Tempat, tgl. lahir
Jenis Kelamin
Agama
Pekerjaan
Alamat
No. KTP

.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................................................................

Dengan ini menyatakan dengan sebenarnya bahwa :

Nama : ...........................................................................................................................................................
yang ada di Buku Nikah No. ...................................................................................................
Nama : ...........................................................................................................................................................
yang ada di KTP No. .....................................................................................................................................
Nama : ...........................................................................................................................................................
yang ada di KK No. .......................................................................................................................................
Nama : ...........................................................................................................................................................
yang ada di Ijazah No. ..........................................................................................................................
Nama : ...........................................................................................................................................................
yang ada di Surat Kelahiran No. .....................................................................................
adalah satu orang.
Adapun yang dipergunakan dalam Akta / Kutipan Akta Kelahiran ialah
Nama : ....................................................................................................................................................... yang ada di ...................................................................................................................................................................
Untuk menguatkan penyataan yang saya buat, saya sertakan para saksi yang mengetahui
nama-nama tersebut.
Demikian Surat pernyataan ini saya buat dengan sebenarnya dan apabila dikemudian hari
pernyataan saya ini tidak sesuai/tidak benar saya berikut para saksi bertanggung jawab terhadap
semua akibat hukum yang timbul, tidak akan melibatkan Pejabat yang ikut menanda tangani
pernyataan ini dan kami sanggup dituntut dihadapan hakim sesuai dengan hukum yang berlaku.

Madiun, .........................................................................................
Yang menyatakan
Saksi I
Nama
Umur
Pekerjaan
Alamat

(materai
Rp. 6000,00,-)

:
:
:
:

.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

Tanda tangan
Saksi II
Nama
Umur
Pekerjaan
Alamat

___________________________________________

Mengetahui,
Kepala Ds./Kel. ..............................................................

.......................................................................................................................................

___________________________________________

:
:
:
:

.......................................................................................................................................

.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................

Mengetahui,
Kepala KUA Kec. Dolopo