F.

1-58

(Kop Dinas Kependudukan dan Pencatatan Sipil) F.1-58

PROVINSI : *)
PROVINCE
KABUPATEN/KOTA : *)
REGENCY / CITY
KECAMATAN : *)
DISTRICT
DESA/KELURAHAN : *)
VILLAGE
DUSUN/DUKUH/KAMPUNG :
SUB VILLAGE

SURAT KETERANGAN PINDAH DATANG

ORANG ASING DALAM WILAYAH NEGARA KESATUAN
REPUBLIK INDONESIA
INFORMATION LETTER OF THE FOREIGNER MOVING INTO THE UNITY STATE
OF INDONESIAN REPUBLIC

NO: ………………………………….

DATA DAERAH ASAL

ORIGIN TERRITORY DATA

1. NIK Pemohon
Number of Population Identity

2. Nama Lengkap
Full Name

3. Nomor Kartu Keluarga

(Diisi oleh OA Tinggal Tetap)
Family Card Number
(Filled by the foreigner who
stay permanently)

4. Nama Kepala Keluarga

(Diisi oleh OA Tinggal Tetap)
Head of Family Name
(Filled by the foreigner who
stay permanently)

5. Alamat RT RW
Address
Dusun/Dukuh/Kampung
Sub Village

a. Desa/Kelurahan / Village c. Kab/Kota

Regency/City

b. Kecamatan / District d. Provinsi

Province

Kode Pos Telepon

Post Code Phone

6. Nomor & Tgl KITAS/KITAP

Number and date of TSPC/
PSPC ***)

DATA KEPINDAHAN
THE MOVEMENT DATA

1. Pekerjaan / Occupation 3. Keamanan / Security 5. Perumahan / Housing 7. Lainnya (sebutkan)

1. Alasan Pindah
2. Pendidikan / Education 4. Kesehatan / Healthy 6. Keluarga / Family Other (mention)
The Reason of Moving

2. Alamat Tujuan Pindah RT RW

Destination Moving Address
Dusun/Dukuh/Kampung
Sub Village

a. Desa/Kelurahan / Village c. Kab/Kota **)

Regency/City
b. Kecamatan / District d. Provinsi **)
Province

Kode Pos Telepon

Post Code Phone

3. Klasifikasi Pindah 1. Antar Kab/Kota / Between Regency/City

Moving Clasification 2. Antar Provinsi / Between Province

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4. Nama Sponsor
(Diisi oleh OA Tinggal Terbatas)
Sponsor’s name
(Filled by the foreigner who
stay temporary)
1. Organisasi Internasional/International Organization
5. Tipe Sponsor 2. Pemerintah/Government
(Diisi oleh OA Tinggal Terbatas) 3. Perusahaan/Company
Sponsor’s Type 4. Perorangan/Personal
(Filled by the foreigner who 5. Tanpa Sponsor/None
stay temporary)
6. Alamat Sponsor RT RW
(Diisi oleh OA Tinggal Terbatas)
Sponsor’s Address
(Filled by the foreigner who
stay temporary) Dusun/Dukuh/Kampung
Sub Village

a. Desa/Kelurahan / Village c. Kab/Kota **)

Regency/City

b. Kecamatan / District d. Provinsi **)

Province

Kode Pos Telepon

Post Code Phone

7. Jenis Kepindahan 1. Kep. Keluarga / Head of Family

(Diisi oleh OA Tinggal Tetap) 2. Kep. Keluarga dan Seluruh Angg. Keluarga / Head of family and all of the family member
Kind of Movement
(Filled by the foreigner who 3. Kep. Keluarga dan Sbg. Angg. Keluarga / Head of family and some of the family member
stay permanently) 4. Angg. Keluarga / Family member

8. Status KK 1. Numpang KK / Join the family card

Bagi Yang Tidak Pindah 2. Membuat KK Baru / Making the new family card
(Diisi oleh OA Tinggal Tetap) 3. Nomor KK Tetap / Permanent family card number
Family Card Number Status For
Those Who Didn’t Move
(Filled by the foreigner who
stay permanently)

9. Status KK 1. Numpang KK / Join the family card

Bagi Yang Pindah 2. Membuat KK Baru / Making the new family card
(Diisi oleh OA Tinggal Tetap)
3. Nomor KK Tetap / Permanent family card number
Family Card Number Status For
Those Who Move
(Filled by the foreigner who
stay permanently)

10. Keluarga Yang Pindah

The Family Who Move

MASA BERLAKU
NO. NIK NAMA KITAS/KITAP s/d SHDK
Number of Population Identity NAME Expire of R of FM
TSPC/PSPC Until ****)

Pelaporan di daerah tujuan paling lambat 30 hari kerja sejak diterbitkannya Surat Keterangan Pindah Datang (SKPD) di daerah asal.
(Reporting in the purpose territory not late for 30 workdays from the information moving letter published in the origin territory)

………………, ……………………

Dikeluarkan oleh :
Pemohon
The Applicant Kepala Dinas Kependudukan dan
Pencatatan Sipil Daerah Asal
Published by
Head of Population and Civil
Registration (Origin Territory)

(…………………………………) (…………………………………)

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DATA DAERAH TUJUAN
PURPOSE TERRITORY DATA

1. NIK Pemohon
Number of Population Identity

2. Nama Pemohon
Applicant’s Name

3. Nomor Kartu Keluarga

Pemohon Di daerah asal
(Diisi oleh OA Tinggal Tetap)
Family Card number in the
Origin territory
(Filled by the foreigner who
stay permanently)

4. Nama Kepala Keluarga

Pemohon Di daerah asal
(Diisi oleh OA Tinggal Tetap)
Head of Family Name
(Filled by the foreigner who
stay permanently)

5. Status KK 1. Numpang KK / Join the family card

Bagi Yang Pindah 2. Membuat KK Baru / Making new family card
(Diisi oleh OA Tinggal Tetap) 3. Nomor KK Tetap / Permanent family card number
Card Number Status for the
moving one
(Filled by the foreigner who
stay permanently)

6. Tanggal Kedatangan
Arrival Date

7. Alamat RT RW
Address

Dusun/Dukuh/Kampung
Sub Village

a. Desa/Kelurahan / Village c. Kab/Kota **)

Regency/City

b. Kecamatan / District d. Provinsi **)

Province
Kode Pos Telepon
Post Code Phone

8. Keluarga Yang Datang

Family who Arrive

MASA BERLAKU
NO. NIK NAMA KITAS/KITAP s/d SHDK
Number of Population Identity NAME Expire of R of FM
TSPC/PSPC Until ****)

………………, ……………………

Dikeluarkan oleh :
Kepala Dinas Kependudukan dan
Pencatatan Sipil Daerah Tujuan
Pemohon Published by
The Applicant Head of Population and Civil
Registration (Purpose Territory)

(…………………………………) (……………………………………)
Keterangan :
Note
*) Filled by the official
**) Filled if moving between regency/city or between province
***) TSPC = Temporary Stay Permit Card and PSPC = Permanent Stay Permit Card
****) R of FM = Relationship of Familly Members

106