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To

The Chief Of Civil

Registry Office

Badung Municipality

I, (The Undersigned) born at on
,
Religion . Occupation . Permanent address
. Previously married: . Son of
address
And address

Together with
born at on
Religion: . Occupation: . Permanent address:
. Previously married: .Daughter of
address and
address
Here with report to the Chief of the Civil Registry Office Badung Municipality. That we intend to
marry and request that information be registered and announced accordingly.

Denpasar, 20 August 2015

(
)

(
)

Religion : 4. Name : 2. Age : 3. BRIDE – TO – BE 1. FATHER OF THE BRIDE – TO – BE 1. Place and date of birth : 4.Solemnization – on - Date : 20 August 2015 Day : Thursday Time : 10. Place and date of Birth : 4. Religion : 5. Address : . Name : 2. Present address : 7. Address : III. FATHER OF THE GROOM – TO – BE 1. Marital Status : 9. Age : 3. Present address : 7. Nationality : 3. Ex. Nationality : 3. Age : 3. Religion : 4. MOTHER OF THE GROOM – TO – BE 1.00 NO QUESTION ANSWER II. Occupation : 6. Address : IV. Occupation : 5. Religion : 5. Name : 2. Husban’s name : V. Marital status : 9. Name : 2. Occupation : 6. Occupation : 5. GROOM – TO – BE 1. Ex Wife Name : II. Religion : 4. Name : 2. Occupation : 5. Previous : 8. Previous : 8.

Name : 2. Religion : 4. SECOND WITNESS 1. MOTHER OF BRIDE – TO – BE 1. Religion : 4. Address : Denpasar. Occupation : 5. Occupation : 5. Occupation : 5. Address : VII. Religion : 4. . Age : 3. Name : 2. Age : 3.VI. II Name of witness 2. FIRST WITNESS 1. Name : 2. Age : 3. 28 December 2014 ( ) ( ) Signature of witnesses: I Name of witness 1. Address : VIII.