Kaedah Kaedah Perkahwinan Cerai Dan Rujuk Borang Dan Fi 2009

NEGERI SELANGOR
Warta Kerajaan
DITERBITKAN DENGAN KUASA
GOVERNMENT OF SELANGOR GAZETTE

PUBLISHED BY AUTHORITY
Jil. 62 TAMBAHAN No. 12

10hb September 2009 PERUNDANGAN
No. 19
Sel. P.U. 19.

ENAKMEN UNDANG-UNDANG KELUARGA ISLAM
(NEGERI SELANGOR) 2003
Kaedah-kaedah Perkahwinan, Cerai dan Rujuk

(Borang dan Fi) 2009
SUSUNAN Kaedah
Kaedah
1. Nama
2. Borang
3. Fi
4. Ketidakpatuhan
5. Pemansuhan
6. Kecualian
Jadual
Sel. P.U. 19. 84

Kaedah-kaedah Perkahwinan, Cerai dan Rujuk

(Borang dan Fi) 2009
Pada menjalankan kuasa yang diberi oleh seksyen 135 Enakmen Undang-
undang Keluarga Islam (Negeri Selangor) 2003 [Enakmen No. 2 tahun 2003],
Duli Yang Maha Mulia Sultan atas nasihat Majlis, membuat kaedah-kaedah
seperti yang berikut:
Nama
1. Kaedah-kaedah ini bolehlah dinamakan Kaedah-kaedah Perkahwinan,

Cerai dan Rujuk (Borang dan Fi) 2009.
Borang
2. Borang yang ditetapkan dalam Jadual Pertama kepada Kaedah-kaedah ini
hendaklah digunakan bagi segala urusan rasmi berkenaan dengan perkahwinan,
cerai dan rujuk di bawah Enakmen. Borang itu hendaklah di dalam Bahasa
Malaysia tulisan Rumi ataupun Jawi.
Fi
3. Fi yang ditetapkan dalam Jadual Kedua kepada Kaedah-kaedah ini hendaklah
dikenakan bagi semua urusan yang ditentukan di dalamnya.
Ketidakpatuhan
4. Ketidakpatuhan dengan mana-mana borang yang ditetapkan tidak menyebabkan

permohonan, prosiding atau pembicaraan batal tetapi Pendaftar, Hakim Syariah
atau Mahkamah Syariah, boleh mengarahkan pihak berkenaan meminda atau
membetulkan borang itu mengikut apa-apa bentuk dan menurut apa-apa terma
dan syarat yang difikirkan patut.
Pemansuhan
5. Kaedah-kaedah Perkahwinan, Cerai dan Ruju’ (Borang dan Fee) 1989
[Sel. P.U. 12/1989] dimansuhkan.
Kecualian
6. Semua kaedah, perisytiharan, perintah, pemberitahuan, notis, borang, surat

kebenaran dan pelantikan yang dikeluarkan atau dibuat di bawah atau menurut
kuasa mana-mana peruntukan Undang-undang bertulis yang mansuh menurut
kuasa oleh kaedah-kaedah ini hendaklah terus berkuat kuasa, setakat yang tidak
bertentangan dengan kaedah-kaedah ini, sehingga dibatalkan atau digantikan
oleh peraturan-peraturan, kaedah-kaedah, perisytiharan, perintah, pemberitahuan,
notis, borang, surat kebenaran, atau pelantikan yang dikeluarkan atau dibuat
di bawah Kaedah-kaedah ini.
85 Sel. P.U. 19.
Jadual Pertama
BORANG 1
[Seksyen 4]

Akuan Pengesahan Pemastautinan
A. TERMA DAN SYARAT PERMOHONAN:
1. Pemohon mestilah tinggal sekurang-kurangnya 4 bulan atau lebih di dalam Kariah di

mana permohonan ini dibuat.
2. Satu salinan kad pengenalan pemohon.
3. Satu salinan kad pengenalan saksi atau satu salinan bil elektrik, bil air atau bil telefon
terkini.
4. Pengesahan hendaklah dibuat oleh: Penghulu/Ketua Kampung/Pengerusi Jawatankuasa

Kemajuan dan Keselamatan Kampung/Nazir/Pengerusi Jawatankuasa Penduduk/Pengerusi
Taman Perumahan.
B. BUTIRAN PEMOHON:
1. Nama: . ............................................................................................................................................
2. No. Kad Pengenalan/Pasport: .........................................................................................................
3. Alamat dalam Kad Pengenalan/Pasport: . .......................................................................................

.........................................................................................................................................................
.........................................................................................................................................................
4. Alamat Kediaman: ..........................................................................................................................

.........................................................................................................................................................
.........................................................................................................................................................
5 No. Telefon: (R) ....................................(P) ..................................... (H/P) ...................................
6. Nama Masjid/Kariah: ....................................................Daerah: ...................................................
7. Tempoh menetap di Negeri Selangor: ................................Tahun ...................................... Bulan
C. PERAKUAN PEMOHON:
Saya mengaku bahawa segala maklumat yang saya kemukakan adalah benar.
Tarikh: Hijrah ................................................ .......................................................

Masihi Tandatangan Pemohon
Sel. P.U. 19. 86
D. BUTIRAN SAKSI:
1. Nama: . ............................................................................................................................................
2. No. Kad Pengenalan/Pasport: .........................................................................................................
3. Alamat kediaman: ...........................................................................................................................
.........................................................................................................................................................

4. No. Telefon: (R)....................................(P) .............................(H/P) .............................................
Saya mengaku bahawa segala maklumat yang dikemukakan di atas adalah benar.
Tarikh: Hijrah ........................................... ..........................................................

Masihi Tandatangan Saksi
E. PENGESAHAN PEMASTAUTINAN:
Saya ...................................................................No. Kad Pengenalan/Pasport: ...................

(Nama individu yang mengesahkan dokumen)
sebagai ..........................................................................................................setelah meneliti

(Jawatan)
butir-butir yang dikemukakan, adalah berpuas hati dengan perakuan dan maklumat yang
diberikan oleh ................................................................................................... Oleh yang

(Nama pemohon)
demikian, saya mengesahkan bahawa beliau adalah salah seorang pemastautin di dalam
kawasan saya dan telah tinggal di kawasan ini selama ................ tahun .................. bulan.
Tarikh: Hijrah ......................................... ...................................................................

Masihi Tandatangan dan Cop Rasmi Jawatan
87 Sel. P.U. 19.
Jadual Pertama
BORANG 2A
[Seksyen 16]

Permohonan Kebenaran Berkahwin (Lelaki)
1. Nama: . ..................................................................................................................................................
2. No. Kad Pengenalan/Pasport: .............................................Warganegara: ..........................................
Tarikh Lahir: .................................................................Bangsa: .........................................................
Alamat (Rumah): ..................................................................................................................................
...............................................................................................................................................................
Kelulusan Akademik: . ..........................................................................................................................
Pekerjaan: ...................................................................... Pendapatan: .................................................
Alamat (Pejabat): .................................................................................................................................
...............................................................................................................................................................
No. Telefon: (R) ............................................(P) .....................................(H/P) ..................................
Tarikh Masuk Islam (jika mualaf): ................................ No. Kad Perakuan Islam: ............................
3. Saya memohon berkahwin dengan: ......................................................................................................
No. Kad Pengenalan/Pasport: ...............................................................................................................
Warganegara: ........................................................................................................................................
Tarikh Lahir: ................................................................ Bangsa: ........................................................
Alamat (Rumah): ..................................................................................................................................
...............................................................................................................................................................
Pekerjaan: .............................................................................. Pendapatan: ........................................
Alamat (Pejabat): ..................................................................................................................................
...............................................................................................................................................................
No. Telefon: (R) ...................................... (P) ................................. (H/P) ..........................................
Tarikh Masuk Islam (jika mualaf): ............................. No. Kad Perakuan Islam: ...............................
4. Saya memohon untuk melangsungkan perkahwinan (akad nikah) ini pada Hijrah ............................
Masihi
beralamat di: .........................................................................................................................................

...............................................................................................................................................................
Nama Masjid/Kariah: ...................................................Daerah: ............................................
Negeri: ..........................................................Negara: ...........................................................

Sel. P.U. 19. 88
5. Saya ialah seorang *teruna/duda.

5.1 Jika duda cerai mati, No. Sijil Kematian Isteri: ........................................................................
5.2 Jika duda cerai hidup, No. Surat Perakuan Cerai: ....................................................................
6. Saksi bagi pengesahan butiran diri pemohon ialah:

i. Nama: . ............................................................................................................................................
No. Kad Pengenalan/Pasport: .........................................................................................................
Alamat (Rumah): ............................................................................................................................
.........................................................................................................................................................
Alamat (Pejabat): ............................................................................................................................
.........................................................................................................................................................
No. Telefon: (R) .......................................(P) ...................................(H/P) ...................................
ii. Nama: . ............................................................................................................................................
No. Kad Pengenalan/Pasport: .........................................................................................................
Alamat (Rumah): ............................................................................................................................
.........................................................................................................................................................
Alamat (Pejabat): ............................................................................................................................
.........................................................................................................................................................
No. Telefon: (R) ..............................(P) ................................(H/P) .................................
PENGAKUAN PEMOHON DAN SAKSI
Kami mengaku segala maklumat yang terkandung di dalam borang ini adalah benar dan sekiranya
mana-mana maklumat itu palsu maka kami melakukan suatu kesalahan dan boleh dihukum
di bawah seksyen 38, Enakmen Undang-undang Keluarga Islam (Negeri Selangor) 2003 “Jika
seseorang, bagi maksud mendapatkan suatu perkahwinan dilakukan di bawah Enakmen ini,
sengaja membuat sesuatu akuan, atau pernyataan yang palsu, maka orang itu adalah melakukan
suatu kesalahan dan hendaklah dihukum denda tidak melebihi dua ribu ringgit atau penjara
tidak melebihi setahun atau kedua-duanya denda dan penjara itu.”
Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................

Masihi Tandatangan Saksi Pertama
Tarikh: Hijrah ………………………………. ..............................................................

Masihi Tandatangan Saksi Kedua
89 Sel. P.U. 19.
ULASAN PENOLONG PENDAFTAR NIKAH
Semua keterangan yang tercatat oleh pemohon di atas ini adalah benar dan dia adalah seorang
yang *bujang/bercerai hidup/bercerai mati pada …………..............……...…............. berdasarkan
keterangan oleh *dua orang saksi/surat perakuan cerai/no. sijil kematian/perintah faraq oleh Mahkamah
Syariah saman no. .........................................................................................................................
KETERANGAN LAIN:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
Tarikh: Hijrah …………………………. .........................................................................

Masihi Tandatangan Penolong Pendaftar Nikah
dan Cop Rasmi
ULASAN KETUA PENDAFTAR/PENDAFTAR
Permohonan *diluluskan/tidak diluluskan.
........................................................................................................................................................
........................................................................................................................................................
Tarikh: Hijrah …………………………. .........................................................................

Masihi Tandatangan Ketua Pendaftar/Pendaftar
dan Cop Rasmi
Peringatan: Permohonan ini hendaklah disampaikan kepada Pendaftar sekurang-kurangnya tujuh hari sebelum
tarikh akad nikah dijalankan.
* Potong yang tidak berkenaan.

Sel. P.U. 19. 90
Jadual Pertama
BORANG 2B
[Seksyen 23]

Permohonan Kebenaran Berkahwin (Poligami)
1. Nama: . ..................................................................................................................................................
2. No. Kad Pengenalan/Pasport: ......................................... Warganegara: ..............................................
Tarikh Lahir: ..................................................................... Bangsa: .....................................................
Alamat (Rumah): ..................................................................................................................................
...............................................................................................................................................................
Pekerjaan: ........................................................................ Pendapatan: ...............................................
Alamat (Pejabat):...................................................................................................................................
...............................................................................................................................................................
No. Telefon: (R) ....................................... (P) ................................... (H/P) .......................................
Tarikh masuk Islam (jika mualaf): ................................. No. Kad Perakuan Islam: ...........................
3. Saya memohon berkahwin dengan: ......................................................................................................
No. Kad Pengenalan/Pasport: ........................................... Warganegara: ...........................................
Tarikh Lahir: ............................................................. Bangsa: .............................................................
Alamat (Rumah): ..................................................................................................................................
...............................................................................................................................................................
Pekerjaan: ................................................................ Pendapatan: .......................................................
Alamat (Pejabat): ..................................................................................................................................
...............................................................................................................................................................
No. Telefon: (R) ................................. (P) ................................. (H/P) ...............................................
Tarikh Masuk Islam (jika mualaf): .................................No. Kad Perakuan Islam: ............................
91 Sel. P.U. 19.
4. Saya memohon untuk melangsungkan perkahwinan (akad nikah) ini pada Hijrah …….…...............
Masihi
beralamat di:...........................................................................................................................................
...............................................................................................................................................................
Nama Masjid/Kariah: ......................................................... Daerah: ...................................................
Negeri: ................................................................ Negara: ...................................................................
5. Saya adalah suami kepada:

i. Nama isteri pertama: ...................................................................................................................
No. Kad Pengenalan/Pasport: ........................................ Tarikh Lahir: ......................................
Bilangan Anak: ............................ orang ( L/ P)
Alamat: .......................................................................................................................................
......................................................................................................................................................
ii. Nama isteri kedua: ......................................................................................................................

No. Kad Pengenalan/Pasport: ............................................ Tarikh Lahir: ..................................
Bilangan Anak: ............................. orang ( L/ P)
Alamat: .......................................................................................................................................
.....................................................................................................................................................
iii. Nama isteri ketiga: ......................................................................................................................

No. Kad Pengenalan/Pasport: ............................... Tarikh Lahir: .............................................
Bilangan Anak: .......................... orang ( L/ P)
Alamat: .......................................................................................................................................
.....................................................................................................................................................
i. Nama: ............................................................. No. Kad Pengenalan/Pasport: ............................

Alamat (Rumah): ........................................................................................................................
.....................................................................................................................................................
Alamat (Pejabat): ........................................................................................................................
.....................................................................................................................................................
No. Telefon: (R) ...............................(P) ...................................(H/P) ........................................
ii. Nama: ........................................................... No. Kad Pengenalan/Pasport: ..……….........…..

Alamat (Rumah): ........................................................................................................................
.....................................................................................................................................................
Alamat (Pejabat): ........................................................................................................................
.....................................................................................................................................................
No. Telefon: (R) ............................... (P) ................................... (H/P) ......................................
Sel. P.U. 19. 92
Perhatian:
Mengikut subseksyen 23(4), Enakmen Undang-undang Keluarga Islam (Negeri Selangor) 2003,
“Permohonan untuk kebenaran hendaklah dikemukakan kepada Mahkamah mengikut cara
yang ditetapkan dan hendaklah disertai dengan suatu ikrar menyatakan alasan-alasan mengapa
perkahwinan yang dicadangkan itu dikatakan patut atau perlu, pendapatan pemohon pada masa
itu, butir-butir komitmennya dan kewajipan tanggungan kewangannya yang patut ditentukan,
bilangan orang tanggungannya, termasuk orang yang akan menjadi tanggungannya berikutan
dengan perkahwinan yang dicadangkan itu, dan sama ada izin atau pandangan isteri atau
isteri-isterinya yang sedia ada telah diperoleh atau tidak terhadap perkahwinannya yang
dicadangkan itu.”
PENGAKUAN PEMOHON DAN SAKSI
Kami mengaku segala butir-butir yang terkandung di dalam borang ini adalah benar dan sekiranya
butir-butir itu palsu maka kami melakukan suatu kesalahan dan boleh dihukum di bawah seksyen
38, Enakmen Undang-undang Keluarga Islam (Negeri Selangor) 2003 “Jika seseorang, bagi maksud
mendapatkan suatu perkahwinan dilakukan di bawah Enakmen ini, sengaja membuat sesuatu
akuan, atau pernyataan yang palsu, maka orang itu adalah melakukan suatu kesalahan dan
hendaklah dihukum denda tidak melebihi dua ribu ringgit atau penjara tidak melebihi setahun
atau kedua-duanya denda dan penjara itu.”
Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................


..................................................................................................…………………………….............
..................................................................................................…………………………….............
..................................................................................................…………………………….............
Tarikh: Hijrah …………………………. .........................................................................

dan Cop Rasmi

.................................................................................................…………………………….............
..................................................................................................…………………………….............
..................................................................................................…………………………….............
Tarikh: Hijrah …………………………. .........................................................................

Masihi Tandatangan Ketua Pendaftar/Pendaftar Nikah
dan Cop Rasmi
93 Sel. P.U. 19.
Jadual Pertama
BORANG 2C
[Seksyen 16]

Permohonan Kebenaran Berkahwin (Perempuan)
1. Nama: . ..................................................................................................................................................
2. No. Kad Pengenalan/Pasport: .................................................. Warganegara: ....................................
Tarikh Lahir: ........................................................... Bangsa: ............................................................
Anak yang ke: ................................. Tarikh Nikah Ibu bapa: .............................................................
Alamat (Rumah): ..................................................................................................................................
..............................................................................................................................................................
Pekerjaan: ..................................................................... Pendapatan: ..................................................
Alamat (Pejabat): ..................................................................................................................................
..............................................................................................................................................................
No. Telefon: (R) ................................. (P) ............................... (H/P) .................................................
Tarikh Masuk Islam (jika mualaf): ..................... No. Kad Perakuan Islam: .......................................
3. Saya bersetuju dan memohon berkahwin dengan: . ..............................................................................
No. Kad Pengenalan/Pasport: .............................................. Warganegara: ........................................
Tarikh Lahir: ........................................................ Bangsa: ................................................................
Alamat (Rumah): ..................................................................................................................................
...............................................................................................................................................................
Pekerjaan: ............................................................ Pendapatan: ..........................................................
Alamat (Pejabat): ..................................................................................................................................
..............................................................................................................................................................
No. Telefon: (R) ................................. (P) ............................... (H/P) .................................................
Tarikh Masuk Islam (jika mualaf): .............................. No. Kad Perakuan Islam: ..............................
Sel. P.U. 19. 94
4. Saya memohon untuk melangsungkan perkahwinan (akad nikah) ini pada
Hijrah ........................................ di ......................................................................................................

Masihi
..............................................................................................................................................................
Nama Masjid/Kariah: ...................................................... Daerah: .....................................................
Negeri: .................................................................... Negara: ..............................................................
5. Saya ialah seorang *anak dara/thaiyib/janda/balu dan tidak dalam ‘idah sesiapa.
6. Surat Perakuan Cerai/No. Sijil Kematian: ....................................................... adalah dilampirkan.
7. Saya bersetuju penama di bawah adalah sebagai wali perkahwinan saya:
Nama:.....................................................................................................................................................
No. Kad Pengenalan/Pasport: .............................................. Tarikh Lahir: .........................................
Alamat (Rumah):...................................................................................................................................
..............................................................................................................................................................
Hubungan wali dengan pemohon: ........................................................................................................
i. Nama: ..........................................................................................................................................
No. Kad Pengenalan/Pasport: .....................................................................................................
Alamat (Rumah): ........................................................................................................................
......................................................................................................................................................
Alamat (Pejabat): ........................................................................................................................
......................................................................................................................................................
No. Telefon: (R) ........................... (P) ................................ (H/P) .............................................
ii. Nama: .........................................................................................................................................
Alamat (Rumah): ........................................................................................................................

......................................................................................................................................................
Alamat (Pejabat): ........................................................................................................................
......................................................................................................................................................
No. Telefon: (R) ........................... (P) ................................ (H/P) .............................................
PENGAKUAN PEMOHON, WALI DAN SAKSI
Kami mengaku segala maklumat yang terkandung di dalam borang ini adalah benar dan sekiranya
maklumat itu palsu maka kami melakukan suatu kesalahan dan boleh dihukum di bawah seksyen 38,
Enakmen Undang-undang Keluarga Islam (Negeri Selangor) 2003 “Jika seseorang, bagi maksud
mendapatkan suatu perkahwinan dilakukan di bawah Enakmen ini, sengaja membuat sesuatu
akuan, atau pernyataan yang palsu, maka orang itu adalah melakukan suatu kesalahan dan
hendaklah dihukum denda tidak melebihi dua ribu ringgit atau penjara tidak melebihi setahun
atau kedua-duanya denda dan penjara itu.”
95 Sel. P.U. 19.
Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................

Masihi Tandatangan Wali
Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................


..................................................................................................…………………………….............
..................................................................................................…………………………….............
..................................................................................................…………………………….............
Tarikh: Hijrah …………………………. .........................................................................

dan Cop Rasmi
Permohonan *diluluskan/tidak diluluskan.
... …………………………………………………………………………………………………………
........................................................................................................................................................
Tarikh: Hijrah …………………………. .........................................................................

Masihi Tandatangan Ketua Pendaftar/Pendaftar
dan Cop Rasmi
Peringatan: Permohonan ini hendaklah disampaikan kepada Pendaftar sekurang-kurangnya tujuh hari sebelum
tarikh akad nikah dijalankan.
* Potong yang tidak berkenaan.

Sel. P.U. 19. 96
Jadual Pertama
BORANG 2D
[Seksyen 13]

Persetujuan Wali dan Wakalah Wali
persetujuan wali
Saya . ..............................................................................................................................................
(Nama Wali)
adalah .................................... kepada ...........................................................................................
(Hubungan) (Nama Pengantin Perempuan)
dengan ini membuat pengakuan bahawa saya bersetuju dengan perkahwinan di antara . .............
.................................................................... dengan ......................................................................
(Nama Pengantin Perempuan) (Nama Pengantin Lelaki)
........................................... dengan mas kahwinnya RM ...................................... *tunai/hutang.
Saya akan menikahkan *sendiri/mewakilkan kepada *Ketua Pendaftar/Pendaftar/Penolong

Pendaftar Nikah, .................................................................................. untuk mengakadnikahkan
(Nama orang yang diwakilkan)
perkahwinan ini.
Tarikh: Hijrah …………………………. .........................................................................

wakalah wali
Saya . ..............................................................................................................................................
(Nama Wali)
adalah .................................... kepada ...........................................................................................
(Hubungan) (Nama Pengantin Perempuan)
dengan ini mewakilkan kepada ......................................................................................................
(Nama wakil)
sebagai ...........................................................................................................................................
(Jawatan)
untuk mengakadnikahkan .............................. saya dengan ..........................................................
(Hubungan) (Nama Pengantin Lelaki)
........................................... dengan mas kahwinnya RM ...................................... *tunai/hutang.
Tarikh: Hijrah …………………………. .........................................................................

Saya dengan ini menerima Wakalah Wali di atas. ......................................................

Tandatangan Penerima Wakalah
97 Sel. P.U. 19.
saksi wakalah wali:
i. Nama: ..........................................................................................................................................
Alamat (Rumah): ........................................................................................................................
......................................................................................................................................................
.........................................................................
Tandatangan Saksi Pertama
ii. Nama: ..........................................................................................................................................
Alamat (Rumah): ........................................................................................................................
......................................................................................................................................................
.........................................................................
Tandatangan Saksi Kedua
pengesahan wakalah wali
Saya . ............................................................................................ mengesahkan bahawa Wakalah

*(Ketua Pendaftar/Pendaftar/Penolong Pendaftar Nikah)
Wali yang dibuat di atas adalah di hadapan saya di . .................................................. dan ianya
(Alamat tempat Wakalah Wali dibuat)
menepati kehendak Hukum Syarak.
Tarikh: Hijrah …………………………. .........................................................................

Masihi Tandatangan Ketua Pendaftar/Pendaftar/
Penolong Pendaftar Nikah dan Cop Rasmi
* Potong yang tidak berkenaan

(Borang ini hendaklah disertakan bersama Borang 2C)
Sel. P.U. 19. 98
Jadual Pertama
BORANG 3A
[Seksyen 17]

Kebenaran Berkahwin dalam Negeri Selangor (Lelaki)
Bilangan Kebenaran: ......................................................................................................................
Bilangan Permohonan: ...................................................................................................................
Pendaftar,
Perkahwinan, Perceraian dan Rujuk,
……………………………………………………..
……………………………………………………..
Saya . ..............................................................................................................................................
(Nama Pendaftar)
Jawatan: . ................................................. Daerah: ........................................................................
Memberi kebenaran kepada . ..........................................................................................................

(Nama Pengantin Lelaki dan No. Kad Pengenalan)
........................................................................................................................................................
untuk berkahwin dengan ................................................................................................................

(Nama Pengantin Perempuan dan No. Kad Pengenalan)
di.....................................................................................................................................................
(Alamat tempat Akad Nikah)
........................................................................................................................................................
........................................................................................................................................................
Sehubungan itu, perkara ini dirujuk kepada pihak tuan untuk tindakan selanjutnya.
Tarikh: Hijrah …………………………. .........................................................................

Masihi Tandatangan Ketua Pendaftar/
Pendaftar dan Cop Rasmi
PERHATIAN:
Kebenaran ini hanya sah dalam tempoh 3 bulan dari tarikh dikeluarkan.
99 Sel. P.U. 19.
Jadual Pertama
BORANG 3B
[Seksyen 17 dan 20]

Kebenaran Berkahwin Luar Negeri Selangor (Lelaki)
Ketua Pendaftar/Pendaftar,
Perkahwinan, Cerai dan Rujuk
Pegawai Kedutaan/Pegawai Konsulat/Pegawai Berkenaan
……………………………………………………..
……………………………………………………..
Tuan,
Saya . ..............................................................................................................................................
(Nama Pendaftar)
Jawatan: . ................................................. Daerah: ........................................................................

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

di ....................................................................................................................................................
(Alamat untuk Akad Nikah)
........................................................................................................................................................
Tarikh: Hijrah …………………………. .........................................................................

PERHATIAN:
Sel. P.U. 19. 100
Jadual Pertama
BORANG 3C
[Seksyen 17]

Kebenaran Berkahwin dalam Negeri Selangor (Perempuan)
Pendaftar,
Perkahwinan, Perceraian dan Rujuk,
……………………………………………………..
……………………………………………………..
Saya . ..............................................................................................................................................
(Nama Pendaftar)
Jawatan: . ................................................. Daerah: ........................................................................

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

di.....................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
Tarikh: Hijrah …………………………. .........................................................................

PERHATIAN:
101 Sel. P.U. 19.
Jadual Pertama
BORANG 3D
[Seksyen 17 dan 20]

Kebenaran Berkahwin Luar Negeri Selangor (Perempuan)
Ketua Pendaftar/Pendaftar,
Perkahwinan, Cerai dan Rujuk
Pegawai Kedutaan/Pegawai Konsulat/Pegawai Berkenaan
……………………………………………………..
……………………………………………………..
Tuan,
Saya . ..............................................................................................................................................
(Nama Pendaftar)
Jawatan: . ................................................. Daerah: ........................................................................

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

di ....................................................................................................................................................
........................................................................................................................................................
Tarikh: Hijrah …………………………. .........................................................................

PERHATIAN:
Sel. P.U. 19. 102
Jadual Pertama
BORANG 4A
[Seksyen 26]
Rekod Catatan Akad Nikah
.........................................................................
(Tandatangan, Tarikh & Cop Rasmi)
Pendaftar/Pen. Pendaftar
Nikah, Cerai & Rujuk
103 Sel. P.U. 19.
surat perakuan ta’liq
Pengantin Lelaki telah berta’liq seperti berikut:
Saya mengaku apabila saya meninggalkan isteri saya
..................................................................................................
selama empat bulan Hijrah berturut-turut atau

lebih dengan sengaja atau paksaan,
atau saya atau wakil saya tiada memberi nafkah yang selayaknya
kepadanya selama tempoh masa yang tersebut
pada hal dia taatkan saya, atau saya melakukan

sebarang mudarat atau lazim menyakiti tubuh badannya,
kemudian dia mengadu kepada Mahkamah Syariah,

dan apabila sabit aduannya
di sisi Mahkamah Syariah, dan dia memberi kepada

Mahkamah Syariah yang menerima bagi pihak saya
sepuluh ringgit maka pada ketika itu tertalaq dia dengan cara talaq khul`
(Tebus Talaq)
Di hadapan saya
........................................................... .........................................
(Tandatangan, Tarikh & Cop Rasmi) Tandatangan Suami
Pendaftar/Pen. Pendaftar
Nikah, Cerai & Rujuk
Perhatian Kepada Pemohon: (Sila lampirkan bersama)
1. surat kebenaran berkahwin atau salinannya dan

dokumen akad nikah (Jika Nikah Dalam Negeri)
2. fi pendaftaran surat perakuan nikah : RM 15.00
3. pendaftar/pen. pendaftar : RM 100.00
4. saksi akad nikah (2 x RM20.00) : RM 40.00

—————
JUMLAH : RM 155.00
—————
Sel. P.U. 19. 104
Jadual Pertama
BORANG 4B
[Seksyen 26]

Surat Perakuan Nikah
Bilangan Daftar: ………................................. Tarikh Daftar: ..............................................
No. Kebenaran Perkahwinan: .........…..........................................................................…..............
Seksyen: .........................................................................................................................................
A. MAKLUMAT PASANGAN
SUAMI
Nama: ……………………………………………………..........………………………………………
No. Kad Pengenalan/Pasport: …….…………………… Umur: ………………..........
Warganegara: …………………………………………...... Bangsa: …........…………...
Alamat: ......……………………………………………………………………………………………..
ISTERI
Nama: …..........…….…………………………………………………………...……………………....
No. Kad Pengenalan/Pasport: ......................................... Umur: ………………..........
Warganegara: …………………………………………...... Bangsa: …........…………...
Alamat: ......……………………………………………………………………………………………..
B. maklumat wali
Nama Wali: …..........…….…………………………………………………………...………………..
No. Kad Pengenalan/Pasport: ................................................ Umur: ................................
Hubungan: …………………………………………..........................................................................
Alamat: ...........................................................................................................................................
........................................................................................................................................................
105 Sel. P.U. 19.
C. MAKLUMAT SAKSI
SAKSI PERTAMA
Nama: …..........…….…………………………………………………………...……………………....
No. Kad Pengenalan/Pasport: …….…………………… Umur: ………………..........
Alamat: ......……………………………………………………………………………………………..
......……………………………………………………………………………………………................
SAKSI KEDUA
Nama: ................…….………………………………………………………..………………………...
No. Kad Pengenalan/Pasport: …….……………………... Umur: ………………..........
Alamat: ......……………………………………………………………………………………………..
......……………………………………………………………………………………………................
D. BUTIR-BUTIR PERNIKAHAN
Tarikh Nikah Hijrah: ………………….……... Hari: ...…...…………. Masa: ...........................

Masihi
Tempat: ..........................................................................................................................................
…………….....................................................................................................................................
Nama Pendaftar/Pen. Pendaftar: .....................................................................................................
Pernikahan kali: ............................................... Isteri ke: .......................................................
Mas Kahwin: RM………….................................................................................... *Tunai/Hutang
Belanja Hantaran: RM.......................…..........................................................................................
Pemberian Lain (Jika ada): ............................................................................................................
Tarikh: ....................... .................................................................

Tandatangan Pendaftar dan Cop Rasmi
E. PERAKUAN TA`LIQ
Suami telah berta`liq selepas majlis akad nikah seperti berikut:
“Saya mengaku apabila saya tinggalkan isteri saya selama empat bulan Hijrah berturut-turut
atau lebih dengan sengaja atau paksaan, atau saya atau wakil saya tidak memberi nafkah yang
selayaknya kepadanya selama tempoh masa yang tersebut pada hal dia taatkan saya, atau saya
melakukan sebarang mudarat atau lazim menyakiti tubuh badannya, kemudian dia mengadu kepada
Mahkamah Syariah, dan apabila sabit aduannya di sisi Mahkamah Syariah, dan dia memberi
kepada Mahkamah Syariah yang menerima bagi pihak saya SEPULUH RINGGIT maka pada
ketika itu tertalaq dia dengan cara Talaq Khul’ (Tebus Talaq)”
Tarikh: ………….………………
……………….….………………………...
Tandatangan Suami
Tarikh: ………….………………
………….….……………………………...
Tandatangan Pendaftar dan Cop Rasmi
Sel. P.U. 19. 106
Jadual Pertama
BORANG 5
[Seksyen 31 dan 33]
Permohonan Pendaftaran Perkahwinan

107 Sel. P.U. 19.
Sel. P.U. 19. 108
109 Sel. P.U. 19.
Sel. P.U. 19. 110
Jadual Pertama
BORANG 6A
[Subseksyen 43(1)]

Permohonan Carian dalam Daftar
Bilangan Permohonan: ..................................................................................................
Tarikh Permohonan: ..................................................................................................
Jenis Daftar: ..................................................................................................
MAKLUMAT PERNIKAHAN
Nama Isteri: ..................................................................................................

No. Kad Pengenalan/pasport: ..................................................................................................
Nama Suami: ..................................................................................................
Tarikh Nikah: ..................................................................................................
Tarikh Cerai: ..................................................................................................
Tarikh Rujuk: ..................................................................................................
Tempat Nikah/Cerai/Rujuk: ..................................................................................................
Tandatangan Pemohon;
............................................................................
(Nama Pemohon)
Tarikh: ................................................................
111 Sel. P.U. 19.
Jadual Pertama
BORANG 6B
[Subseksyen 43(2)]

KEPUTUSAN CARIAN DALAM DAFTAR
Bilangan Permohonan: ..................................................................................................
Tarikh Permohonan: ..................................................................................................
Jenis Daftar: ..................................................................................................
MAKLUMAT PERNIKAHAN
Nama Isteri: ..................................................................................................
Nama Suami: ..................................................................................................
Tarikh Nikah: ..................................................................................................
Tarikh Cerai: ..................................................................................................
Tarikh Rujuk: ..................................................................................................
Tempat Nikah/Cerai/Rujuk: ..................................................................................................
Disahkan bahawa carian telah dibuat di dalam daftar dan keputusannya adalah:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
MAKLUMAT DALAM DAFTAR (jika ada)
Nama dalam Daftar: ..................................................................................................................
Bilangan Daftar: ..................................................................................................................
Tempat Pendaftaran: ..................................................................................................................
Disahkan oleh:
............................................................................
Pendaftar
Tarikh: ................................................................
Sel. P.U. 19. 112
Jadual Pertama
BORANG 7A
[Subseksyen 52(2)]

Permohonan Rujuk
Kepada:
Pendaftar Nikah, Cerai dan Rujuk
Daerah.........................................................
1. MAKLUMAT SUAMI
Nama: . ...................................................................................................................................
No. Kad Pengenalan/Pasport: . ...............................................................................................
Tarikh Lahir: .............................................. Warganegara: . .................................................
Bangsa: ..................................................................................................................................
Alamat (Rumah): ...................................................................................................................
................................................................................................................................................
Pekerjaan: . .............................................................................................................................
No. Telefon: (R) ............................. (P) ................................ (H/P) ............................
2. MAKLUMAT ISTERI
Nama: . ...................................................................................................................................
No. Kad Pengenalan/Pasport: . ...............................................................................................
Tarikh Lahir: .............................................. Warganegara: . .................................................
Negeri/Negara Asal: ...............................................................................................................
Bangsa: ..................................................................................................................................
Alamat (Rumah): ...................................................................................................................
................................................................................................................................................
Pekerjaan: . .............................................................................................................................
No. Telefon: (R) ............................. (P) ................................ (H/P) ............................
3. MAKLUMAT PERCERAIAN
Tarikh Bercerai: .............................. Hari: ............................. Masa: ...........................
Jenis Talak: ..................................... Kali Ke: . ...................... Berjumlah: ...................
Bercerai *di luar/dalam Mahkamah. Kes Mal bilangan: . ....................................................
Tarikh Rujuk Terdahulu (Jika ada): .......................................................................................
113 Sel. P.U. 19.
4. PENGAKUAN SUAMI
Bahawa saya (nama suami) ...................................................................................................
Telah merujuk isteri saya pada ................................ dengan lafaz ..................................
................................................................................................................................................
5. PENGAKUAN ISTERI
Bahawa saya (nama isteri) . ...................................................................................................
redha dirujuk oleh bekas suami saya (nama suami) . ............................................................
................................................................. dan ketika saya dirujuk, saya masih dalam iddah
dengannya. Tarikh tamat iddah saya ialah pada ......................................
6. LAFAZ RUJUK OLEH SUAMI
Bahawa saya (nama suami) ...................................................................................................
rujuk akan isteri saya (nama isteri) .......................................................................................
kepada nikah saya yang terdahulu .........................................................................................
Tarikh lafaz rujuk: .............................................
7. CATATAN PENDAFTAR
................................................................................................................................................
................................................................................................................................................
................................................................... ..............................................................
Tandatangan Suami Tandatangan Isteri
(sekiranya hadir)
Di hadapan saya:
…………………………………………………….…….
Tandatangan Pendaftar/Cop Jawatan/Tarikh
Sila lampirkan:
1- Salinan kad pengenalan suami isteri.
2- Resit pendaftaran permohonan perceraian di Mahkamah Syariah atau surat keputusan
perbicaraan daripada Mahkamah Syariah (jika ada).
Sel. P.U. 19. 114
Jadual Pertama
BORANG 7B
[Subseksyen 52(3)]

Surat Perakuan Rujuk
Bilangan Daftar rujuk :............................................ Tarikh: Hijrah:..........................................

Masihi
A. MAKLUMAT PASANGAN
1. Nama Suami: .........................................................................................................................

No. Kad Pengenalan/Pasport: . ......................................... Tarikh Lahir: . .........................
Bangsa: ........................................................... Warganegara: . .........................................
Alamat (Rumah): ...................................................................................................................
................................................................................................................................................
Tarikh masuk Islam (Jika mualaf): ............................ No. kad perakuan Islam:................
2. Nama Isteri: ...........................................................................................................................

No. Kad Pengenalan/Pasport: . ......................................... Tarikh Lahir: . .........................
Bangsa: ........................................................... Warganegara: . .........................................
Alamat (Rumah): ...................................................................................................................
................................................................................................................................................
Tarikh masuk Islam (Jika mualaf): ............................ No.kad perakuan Islam..................
B. PERAKUAN RUJUK
Saya ..................................................................................................... memperakui bahawa:
(Nama Pendaftar)
(Nama Suami) .................................................................................. telah merujuk isterinya

(Nama Isteri) . ....................................................................................... dengan lafaz: “Saya
Rujuk akan Isteri saya ............................................................................................... kepada
nikah saya yang dahulu (tarikh nikah dahulu)......................................................................”
C. MAKLUMAT AM
Tarikh Rujuk: Hijrah . ..................................... Rujuk kali ke: .........................................
Masihi
Tarikh Nikah: Hijrah . ..................................... Bil. Daftar Nikah: ...................................
Masihi
Tarikh Cerai: Hijrah . ...................................... Bil. Daftar Cerai: …………......….........
Masihi
Kenyataan lain: ......................................................................................................................
Tarikh: Hijrah ................................................ ......................................................
Masihi Tandatangan Pendaftar Nikah dan
Cop Rasmi
115 Sel. P.U. 19.
Jadual Pertama
BORANG 8
[Subseksyen 55(5)]
Surat Perakuan Cerai
1. Bilangan Daftar Cerai: . .........................................................................................................

2. Bilangan Daftar Surat Perakuan Nikah: . ...............................................................................
3. Bilangan Daftar Surat Perakuan Rujuk: . ...............................................................................
4. Bilangan Kes Mal: .................................................................................................................
5. Tarikh Akad Nikah: Hijrah ..............................................

Masih
6. Tarikh Rujuk: Hijrah . ......................................................

Masihi
7. Tempat pernikahan: Daerah: .................................... Negeri/Negara: . .................................
8. Nama Suami: .........................................................................................................................
No. Kad Pengenalan/Pasport: . ................................... Bangsa: ........................................
Tarikh Lahir: ............................................................ Warganegara:.......................................
Alamat (Rumah):.....................................................................................................................
Pekerjaan:................................................................................................................................
9. Nama Isteri: ...........................................................................................................................
No. Kad Pengenalan/Pasport: . ................................... Bangsa: ........................................
Tarikh Lahir: ............................................................ Warganegara:.......................................
Alamat (Rumah):.....................................................................................................................
Pekerjaan:................................................................................................................................
10. Jenis Perceraian: *Raj’ie/Bain (Bain Sughra/Bain Kubra/Bain Muabbad)
Talaq kali ke: ........................................................... Jumlah Talaq: ....................................
Bayaran Tebus Talaq (Jika ada): . ..........................................................................................
Cara Bercerai: *Dengan Kebenaran Mahkamah/Tanpa Kebenaran Mahkamah
Tempat Bercerai: ....................................................................................................................
Tarikh Bercerai: Hijrah ....................................................

Masihi
Cerai dalam *Suci/Haid/Mengandung: . .................................................................................
Kenyataan lain: ...............................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
Tarikh: Hijrah . ........................................... . ............................................................
Masihi Tandatangan Pendaftar dan Cop Rasmi
* Potong yang tidak berkenaan

Sel. P.U. 19. 116
Jadual Kedua
FI

BIL. PERKARA KADAR
1. Kebenaran Berkahwin dalam/luar Negeri Selangor (Lelaki) RM10.00

(Sek. 17)
2. Kebenaran Berkahwin dalam/luar Negeri Selangor (Perempuan) RM10.00

(Sek. 17)
3. Surat Perakuan Nikah RM20.00

(Sek. 26)
4. Salinan Surat Perakuan Nikah RM20.00

(Sek. 26)
5. Carian Daftar Perkahwinan, RM10.00

Perceraian dan Rujuk
(Sek. 43)
6. Surat Perakuan Cerai RM20.00

(Subsek. 55(5))
7. Salinan Surat Perakuan Cerai RM25.00

(Subsek. 55(5))
8. Surat Perakuan Rujuk RM10.00

(Subsek. 52(3))
9. Salinan Surat Perakuan Rujuk RM10.00

(Subsek. 52(3))
Dibuat 11 Ogos 2009

[JAI.Sel.BUUK 02/006/Jld. 6; P.U. Sel. Am 0110/08/TS]
Dato’ Setia Haji Mohamad Adzib bin Mohd Isa

Pengerusi
Majlis Agama Islam Selangor
117 Sel. P.U. 19.
islamic family law (State of Selangor)

enactment 2003
Marriage, Divorce and Rujuk (Forms and Fees) Rules 2009
ARRANGEMENT OF RULES
Rule
1. Citation
2. Form
3. Fees
4. Non-compliance
5. Repeal
6. Saving
Schedule
Sel. P.U. 19. 118
islamic family law (state of selangor)

enactment 2003
Marriage, Divorce and Rujuk (Forms and Fees) Rules 2009
In exercise of the powers conferred by section 135 of the Islamic Family Law
(State of Selangor) Enactment 2003 [Enactment No. 2 of 2003], His Royal
Highness the Sultan on the advice of the Majlis, makes the following rules:
Citation
1. These Rules may be cited as the Marriage, Divorce and Rujuk (Forms
and Fees) Rules 2009.
Form
2. The forms as prescribed in the First Schedule to these Rules shall be used
for all official dealings in connection with marriage, divorce and rujuk under
the Enactment. The form shall be in Bahasa Malaysia in the Romanized or
Jawi script.
Fees
3. The fees as prescribed in the Second Schedule to these Rules shall be

payable for all dealings stated therein.
Non-compliance
4. Non-compliance with any of the forms prescribed shall not render an

application, proceeding or a hearing void but the Registrar, Syariah Judge or
Syariah Court, may direct the party to amend or rectify the forms in such
manner and upon such terms and conditions deem fit.
Repeal
5. The Marriage, Divorce and Ruju’ (Form and Fees) Rules 1989
[Sel. P.U. 12/1989] is repealed.
Saving
6. All rules, proclamations, orders, notifications, notices, forms, authorizations

letters and appointment issued or made under or by virtue of any Written
Law repealed by virtue of this rules shall remain in force, in so far as they
are not inconsistent with this rules, until revoked or replaced by regulation,
rules, proclamations, orders, notifications, notices, forms, authorization letter,
or appointment issued or made under this Rules.
119 Sel. P.U. 19.
First Schedule
FORM 1
[Section 4]
ISLAMIC FAMILY LAW (STATE OF SELANGOR)

ENACTMENT 2003
Declaration of Residential Confirmation
A. TERMS AND CONDITIONS OF APPLICATION:
1. Applicant must stay at least 4 months or more in the Kariah that he/she is applying
for.
2. A copy of applicant’s identity card.
3. A copy of witness’s identity card or the latest copy of electricity bill, water bill or
telephone bill.
4. Certification of the document must be done by: Head of Village/Village Chief/Chairman

of Development and Safety Village Committee/Nazir/Chairman of Residential Association/
Chairman of Taman Perumahan.
B. PARTICULARS OF APPLICANT:
1. Name: . ...........................................................................................................................
........................................................................................................................................
2. Identity Card/Passport No.: ...........................................................................................
3. Address as in Identity Card/Passport: ...........................................................................
........................................................................................................................................
........................................................................................................................................
4. Address of Resident: .....................................................................................................

........................................................................................................................................
........................................................................................................................................
5. Telephone No.: (H) ……...............… (O) ……..........…...… (H/P) …….......…….……
6. Name of Mosque/Kariah: ……….......................…… District: ……......…..….………..
7. Duration of stay within the State of Selangor: …...........… Year(s) ….....…. Month(s)
Sel. P.U. 19. 120
C. DECLARATION OF APPLICANT:
I declare that the all information given is true.
Date: Hijrah ……………………… ……….………………....…………………

Masihi Signature of Applicant
D. PARTICULARS OF WITNESS:
1. Name: . ...........................................................................................................................
2. Identity Card/Passport No.: ...........................................................................................
3. Address of resident: . .....................................................................................................

........................................................................................................................................
4. Telephone No.: (H) ………....….…… (O) …………....……. (H/P) ……………….…...
I declare the all information given above is true.
Date: Hijrah ……………………… ……….………….....………………………

Masihi Signature of Witness
E. RESIDENTIAL CONFIRMATION:
I …………………………................................................…..................................……………
(Name of the individual who is certifying the document)
Identity Card/Passport No.: ………….……..........…......................................................…….
as ……………………………………………………….....……………………. after scrutinize

(Designation)
at the details provided, satisfied with the declaration and information given by …………..
………………….....................………........................ Therefore, I hereby certify that he/she

(Name of applicant)
is a resident in my area and has been living here for …………. year(s) ..............month(s).
Date: Hijrah ……………………… ……….……….....……….........…………………

Masihi Signature and Official Seal of Designation
121 Sel. P.U. 19.
First Schedule
FORM 2A
[Section 16]

ENACTMENT 2003
Application for Permission to Marry (Male)
1. Name: ……………………………………………………………………………………………..
2. Identity Card/Passport No.: ……………………….............. Nationality: ………..................
Date of Birth: …………………………...................... Race: ………………………..............
Address (Home): …………………………………………………………………………….…...
…………………………………………………………………………………………………......
Academic Qualification: ………………………………………………………………………....
Occupation: ……………………………………....... Income: ………………………...………
Address (Office): …………………………………………………………………………….…..
……………………………………………………………………………………………………..
Telephone No.: (H) …………………… (O) ……………………... (H/P) …………..…...…..
Date of conversion to Islam (if mualaf): ……….. Declaration of Islam Card No.: …….....
3. I am applying to marry with: .........................……………………………………………........
Identity Card/Passport No.: ...................................................................................................
Nationality: ………………………………................................................................................
Date of Birth: ………………………….................... Race: ....…………………………….....
Address (Home): ……………………………………………………………………………........
…………………………………………………………………………….………………………..
Academic Qualification: …..……………………………………………………….…………….
Occupation: ……………………………………………. Income: ..……………………………
Address (Office): ..……………………………………………………………………..………...
…………………………………………………………………………………………………......
Telephone No.: (H) …………………… (O) …………………..… (H/P) ……..…………......
Date of conversion to Islam (if mualaf): …..…… Declaration of Islam Card No.: ….........
Sel. P.U. 19. 122
4. I am applying for the marriage solemnization on Hijrah ………………….….…………..….

Masihi
at the address of: ………………………………………….…………………………………......
…………………………………………………………….........……………………………….....
Name of Mosque/Kariah: …………………….............. District: ….....……....…………......
State: ……………………………………………........... Country: ……………………….......
5. I am a *bachelor/widower.
5.1 If widower, divorce by death, Wife’s Death Certificate No.: ……………………..........
5.2 If widower, divorce when alive, Divorce Certificate No.: ………………………….......
6. Witnesses for the verification of applicant’s personal details are:
i. Name: ……………………………………........................................................................
Identity Card/Passport No.: ……………….....................................................................
Address (Home): …………………………………………………………………………...
……………………………………………………………………………………………..…
Address (Office): ……………………………………………………………………….…..
………………………………………………………………………………………………..
Telephone No.: (H) …………………… (O) …………………. (H/P) ……...…………..
ii. Name: ……………………………………........................................................................

Address (Home): …………………………………………………………………………...
……………………………………………………………………………………………..…
Address (Office): ……………………………………………………………………….…..
………………………………………………………………………………………………..
DECLARATION OF APPLICANT AND WITNESSES
We declare that all information stated in this form is true and if any information is false, then
we have committed an offence and punishable under section 38 of the Islamic Family Law (State
of Selangor) Enactment 2003
“Any person who for the purpose of procuring any marriage under this Enactment intentionally
makes any false iqrar or statement commits an offence and shall be punished with fine not
exceeding two thousand ringgit or with imprisonment not exceeding one year or with both
such fine and imprisonment.”
Date: Hijrah ……………………… ……….……….....…………………………

Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of First Witness
Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Second Witness
123 Sel. P.U. 19.
COMMENTS OF THE ASSISTANT REGISTRAR OF MARRIAGE
All of the information stated above by the applicant is true and he is an individual who is a
*bachelor/widower/divorcee on …………………………………………….…………………………
based on the information provided by *the two witnesses/divorce certificate no./death certificate
no./order of faraq from the Syariah Court summon no. …..................…....……………………….
OTHER INFORMATION:
………………………………………………………………………………………………………......
…………………………………………………………………………………………………………...
……………………………………………………………………………………………………….......
Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Assistant Registrar of
Marriage and Official Seal
COMMENTS OF THE CHIEF REGISTRAR/REGISTRAR
Application is *allowed/disallowed.
……………………………………………………………………………………………………………
………………………………………………………………………………………………………......
Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Chief Registrar/Registrar
and Official Seal
Reminder: This application shall serve to the Registrar at least seven days before the date of solemnization
is carried out.
* Delete wherever necessary
Sel. P.U. 19. 124
First Schedule
FORM 2B
[Section 23]

ENACTMENT 2003
Application for Permission to Marry (Polygamy)
1. Name: ……………………………………………………………………………………………..
2. Identity Card/Passport No.: ………………………................ Nationality: ………..................
Date of Birth: …………………………........................ Race: ………………………..............
Address (Home): …………………………………………………………………………….…...
…………………………………………………………………………………………………......
Occupation: ……………………………………......... Income: ………………………...………
Address (Office): …………………………………………………………………………….…..
……………………………………………………………………………………………………..
Date of conversion to Islam (if mualaf): ………............................……………………….....
Declaration of Islam Card No.: ……......………............................………………………......
3. I am applying to marry with: .........................……………………………………………........

Identity Card/Passport No.: ....................................... Nationality:.........................................
Date of Birth: …………………………...................... Race: ....…………………………….....
Address (Home): ……………………………………………………………………………........
…………………………………………………………………………….………………………..
Occupation: ……………………………………………... Income: ..……………………………
Address (Office): ..……………………………………………………………………..………...
…………………………………………………………………………………………………......
Date of conversion to Islam (if mualaf): …..………………………………………………......
Declaration of Islam Card No.: …..........…..………………………………………………......

125 Sel. P.U. 19.

Masihi
at the address of: ………………………………………….…………………………………......
…………………………………………………………….........……………………………….....
Name of Mosque/Kariah: ……………………................ District: ….....……....…………......
State: …………………………………………….............. Country: ……………………….......
5. I am the husband to:

i. Name of first wife: ……………………………………….…………………………….....
Identity Card/Passport No.: ............…………… Date of Birth: ………….…...............
No. of children: ............…………………… ( M/ F)
Address: ……………………………………………………………………………………..
………………………………………………………………………………………………..
ii. Name of second wife: …………………………………….…………………………….....

No. of children: ............…………………… ( M/ F)
Address: ……………………………………………………………………………………..
………………………………………………………………………………………………..
iii. Name of third wife: ……………………………………….…………………………….....

No. of children: ............…………………… ( M/ F)
Address: ……………………………………………………………………………………..
………………………………………………………………………………………………..
i. Name: ………………….................. Identity Card/Passport No.: ………………............

Address (Home): …………………………………………………………………………...
……………………………………………………………………………………………..…
Address (Office): ……………………………………………………………………….…..
………………………………………………………………………………………………..
ii. Name: ………………….................. Identity Card/Passport No.: ………………............

Address (Home): …………………………………………………………………………...
……………………………………………………………………………………………..…
Address (Office): ……………………………………………………………………….…..
………………………………………………………………………………………………..
Sel. P.U. 19. 126
Attention:
In accordance with subsection 23(4) of Islamic Family Law (State of Selangor) Enactment 2003,
“An application for permission shall be submitted to the Court in the prescribed manner and
shall be accompanied by an iqrar stating the grounds on which the proposed marriage is alleged
to be just or necessary, the present income of the applicant, particulars of his commitments
and his ascertainable financial obligations and liabilities, the number of his dependants,
including persons who would be his dependants as a result of the proposed marriage and
whether the consent or views of the existing wife or wives on the proposed marriage have
been obtained.”
DECLARATION OF APPLICANT AND WITNESSES
We declare that all information stated in this form is true and if any information is false, then we
have committed an offence and punishable under section 38 of the Islamic Family Law (State of
Selangor) Enactment 2003 “Any person who for the purpose of procuring any marriage under
this Enactment intentionally makes any false iqrar or statement commits an offence and shall
be punished with fine not exceeding two thousand ringgit or with imprisonment not exceeding
one year or with both such fine and imprisonment.”
Date: Hijrah ……………………… ……….……….....…………………………

Date: Hijrah ……………………… ……….……….....…………………………

Date: Hijrah ……………………… ……….……….....…………………………

…………………………...………………………………………………………………………………
…………………………………………………………………………………………………………...
……………………..…………………………………………………………………………………….
Date: Hijrah ……………………… ……….……….....……..........……………………

Masihi Signature of Assistant Registrar of Marriage
and Official Seal
…………………………...………………………………………………………………………………
…………………………………………………………………………………………………………...
……………………..…………………………………………………………………………………….
Date: Hijrah ……………………… ……….……….....…………………………

and Official Seal
127 Sel. P.U. 19.
First Schedule
FORM 2c
[Section 16]

ENACTMENT 2003
Application for Permission to Marry (Female)
1. Name: ……………………………………………………………………………………………..
2. Identity Card/Passport No.: ………………………................ Nationality: ………..................
Date of Birth: …………………………........................ Race: ………………………..............
The ........................ child of the family Date of Parent’s Marriage (akad): ......................
Address (Home): …………………………………………………………………………….…...
…………………………………………………………………………………………………......
Occupation: ……………………………………......... Income: ………………………...………
Address (Office): …………………………………………………………………………….…..
……………………………………………………………………………………………………..
Date of conversion to Islam (if mualaf): ………..…………………………………………......
Declaration of Islam Card No.: ……..... ………..………………………………………….......
3. I agree and thereby forward my application to marry with: .........................……….…........
Identity Card/Passport No.: ............................................. Nationality: ………………...........
Date of Birth: …………………………...................... Race: ....…………………………….....
Address (Home): ……………………………………………………………………………........
…………………………………………………………………………….………………………..
Occupation: ……………………………………………... Income: ..……………………………
Address (Office): ..……………………………………………………………………..………...
…………………………………………………………………………………………………......
Date of conversion to Islam (if mualaf): …..……………………………………………..........
Declaration of Islam Card No.: …..........…..……………………………………………..........

Sel. P.U. 19. 128

Masihi
at .........................………………………………………….…………………………………......
…………………………………………………………….........……………………………….....
Name of Mosque/Kariah: ……………………................ District: ….....……....…………......
State: …………………………………………….............. Country: ……………………….......
5. I am a *virgin/thaiyib/widower and am not in iddah with anyone.
6. Divorce Certificate No./Death Certificate No.: .………............…………...…… is enclosed.
7. I agree that the person stated below is the wali for my marriage:
Name: ……………………………………………………………………………………………..
Identity Card/Passport No.: ………………………………........ Date of birth: ….........……..
Address (Home): ……….…………………………………………………………………….......
…………………………………………………………………………………………………......
Wali’s relation with applicant: ………………………………………………………………......
i. Name: ……………………………………........................................................................
Address (Home): …………………………………………………………………………...
……………………………………………………………………………………………..…
Address (Office): ……………………………………………………………………….…..
………………………………………………………………………………………………..
ii. Name: ……………………………………........................................................................
Address (Home): …………………………………………………………………………...
……………………………………………………………………………………………..…
Address (Office): ……………………………………………………………………….…..
………………………………………………………………………………………………..

129 Sel. P.U. 19.
DECLARATION OF APPLICANT, WALI AND WITNESSES
We declare that all information stated in this form is true and if any information is false, then we
have committed an offence and punishable under section 38 of the Islamic Family Law (State of
Selangor) Enactment 2003 “Any person who for the purpose of procuring any marriage under
this Enactment intentionally makes any false iqrar or statement commits an offence and shall
be punished with fine not exceeding two thousand ringgit or with imprisonment not exceeding
one year or with both such fine and imprisonment.”
Date: Hijrah ……………………… ……….……….....…………………………

Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Wali
Date: Hijrah ……………………… ……….……….....…………………………

Date: Hijrah ……………………… ……….……….....…………………………

…………………………...………………………………………………………………………………
…………………………………………………………………………………………………………...
Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Assistant Registrar of
Marriage and Official Seal
The application is *allowed/disallowed.
…………………………...………………………………………………………………………………
…………………………………………………………………………………………………………...
……………………..…………………………………………………………………………………….
Date: Hijrah ……………………… ……….……….....…………………………

and Official Seal
Reminder: This application shall serve to the Registrar at least seven days before the date of wedding
solemnization is carried out.

Sel. P.U. 19. 130
First Schedule
FORM 2D
[Section 13]

ENACTMENT 2003
Consent of the Wali and Wakalah of the Wali
CONSENT OF THE WALI
I ………………………………………………..............................……………………………………
(Name of Wali)
is ………….........................................………… to ……………………………………………….....
(Relationship) (Name of Bride)
declare that I agree with the marriage between ……………………...................................... with

(Name of Bride)
…………………………….....................with the mas kahwin of RM ……...........…. *cash/credit.

(Name of Groom)
I will solemnize the marriage *personally/authorize to the *Chief Registrar/Registrar/Assistant
Registrar of Marriage, .................................................................. to carry out the solemnization

(Name of representative)
of the marriage.
Date: Hijrah ……………………… ……….……….....…………………………

WAKALAH OF WALI
I………………………………………………………………….…………………………………...…..
(Name of Wali)
is …………………........………………… to…...................………..………............………………..
(Relationship) (Name of Bride)
by authorize to ..............................…………………..……………………………............................
(Name of representative)
as .................……….…….……………........................................………………….……….............
(Designation)
to solemnize my ……………….…... with ..............………….…......………..................................

(Relationship) (Name of Groom)
with the mas kahwin of RM ………………….. *cash/credit.
Date: Hijrah ……………………… ……….……….....…………………………

With this, I accept the above Wakalah of the Wali.
……………………...............………………...
Signature of the recipient of the Wakalah
131 Sel. P.U. 19.
WITNESSES FOR THE WAKALAH OF THE WALI:
i. Name: ………………………..……………………………………………………………………
Identity Card/Passport No.: ..……………………………………………………………………
Address (Home): ..………………………………………………………………………………..
………………………...……………….………………………..………………….......................
……..…………..…………………………
Signature of the First Witness
i. Name: ………………………..……………………………………………………………………
Identity Card/Passport No.: …….......................………………….............…...…………….…
Address (Home): …………..……………………………………………………………………..
………………………...……………….………………………..………………….......................
……..…………..…………………………
Signature of the Second Witness
CONFIRMATION OF WAKALAH OF THE WALI
I ……………………………………………………………..… verify that the Wakalah of the Wali

*(Chief Registrar/Registrar/Assistant Registrar of Marriage)
stated above is declared in my presence at…….……….…………………………………...............

(Address of place where the Wakalah of the Wali has been done)
and it is in accordance to the requirements of the Syarak Law.
Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Chief Registrar/Registrar/
Assistant Registrar of Marriage and
Official Seal
* Delete wherever necessary.

(This form is forwarded along with Form 2C)
Sel. P.U. 19. 132
First Schedule
FORM 3A
[Section 17]

ENACTMENT 2003
Permission for Marriage within the State of Selangor (Male)
Permission No.: ……………………………................................…………………..……………...
Application No.: ……………………………….................................……………………………....
Registrar,
Marriage, Divorce and Rujuk,
………………………………..............................
………………………………..............................
I………………………………...............................………………………………..............................
(Name of Registrar)
Designation: .….………………………….…… District: ………...……......................……………..
Grant permission to ……...…………………………………………………………….......................

(Name of Groom and Identity Card No.)
………………………………...............................………………………………................................
to marry with ……...…………………………………………………………………………………...

(Name of Bride and Identity Card No.)
at …………………………………………………………………………………………………….….
(Address of Solemnization)
……………………………………………………………………………………………......................
……………………………………………………………………………………………......................
Therefore, this matter is referred to you for further action.
Date: Hijrah ……………………… ……….……….....…………………………

Masihi Signature of Chief Registrar/
Registrar and Official Seal
ATTENTION:
This permission is only valid within 3 months from the date of issuance.
133 Sel. P.U. 19.
First Schedule
FORM 3B
[Sections 17 and 20]

ENACTMENT 2003
Permission for Marriage Out of the State of Selangor (Male)
Permission No.: …………………………………………………..……………...............................
Application No.: ………………………………..………………………………...............................
Chief Registrar/Registrar
Marriage, Divorce and Rujuk
Embassy Official/Consulate Official/Official in Concern
…………………………………………………….
…………………………………………………….
Sir,
I ……………………………………………………..…………………………………………………..
(Name of Registrar)
Designation: .….………………...………....….. District: ……………...………….……………...….

……………………………………………………..………………………………………………….....
to marry with ………………………...………………………………………………………………..

at……………………………………………………………………………………………………..…..
……………………………………………………………………………………………......................
……………………………………………………………………………………………......................
Date: Hijrah ……………………… ……….……….....…………………………

ATTENTION:
Sel. P.U. 19. 134
First Schedule
FORM 3C
[Section 17]

ENACTMENT 2003
Permission for Marriage within the State of Selangor (Female)
Permission No.: …………………………………………………..……………...............................
Application No.: ………………………………..………………………………...............................
Registrar,
Marriage, Divorce and Rujuk,
……………………………………................……
……………………………………................……
I…………………………………………...............................……………………………………….....
(Name of Registrar)
Designation: .….………………………….…… District: ………...……......................……………..

…………………………………………...............................………………………………………......
to marry with ……...…………………………………………………………………………………...

at …………………………………………………………………………………………………….….
……………………………………………………………………………………………......................
……………………………………………………………………………………………......................
Date: Hijrah ……………………… ……….……….....…………………………

ATTENTION:
135 Sel. P.U. 19.
First Schedule
FORM 3D

ENACTMENT 2003
Permission for Marriage Out of the State of Selangor (Female)
Permission No.: …………………………………………………..……………...............................
Application No.: ………………………………..………………………………...............................
Chief Registrar/Registrar
Marriage, Divorce and Rujuk
Embassy Official/Consulate Official/Official in Concern
…………………………………………………….
…………………………………………………….
Sir,
I ………………………………………………………………………………………………...............
(Name of Registrar)
Designation: .….………………...………....….. District: ……………...………….……………...….

………………………………………………………………………………………………..................
to marry with ………………………...………………………………………………………………..

at……………………………………………………………………………………………………..…..
……………………………………………………………………………………………......................
……………………………………………………………………………………………......................
Date: Hijrah ……………………… ……….……….....…………………………

ATTENTION:
Sel. P.U. 19. 136
First Schedule
FORM 4A
[Section 26]
Enactment 2003
Record of Solemnization
……….……….....…………………………
(Signature, Date & Official Seal)
Registrar/Assistant Registrar
Marriage, Divorce & Rujuk
137 Sel. P.U. 19.
declaration of ta’liq
The Groom was pronounciation the ta’liq as follow:
I declare that when I leave my wife
..............................................................................................................
for the duration of four consecutive months of Hijrah or more
deliberately or by force,
or I or my representative does not provide for her lawful maintenance for the said duration
wherein she is loyal to me or

if I cause physical injury on her body
where later she lodges a complaint to the Syariah Court

and when the Syariah Court accept the complaint
and she give to the Syariah Court which received on my behalf an amount of
TEN RINGGIT thereby causing the talaq upon her by way of Talaq Khul’
In the Presence of:
.............................................................. ............................................
(Signature, Date & Official Seal) Signature of Husband
Registrar/Assistant Registrar
Marriage, Divorce & Rujuk
Attention to Applicant: (Please attach together)
1. Marriage Approval Document or its Copy other Marriage Documents

(If Married in the State)
2. Registration fee for Certificate Declaration for Marriage : RM 15.00
3. Registrar/Assistant Registrar : RM 100.00
4. Witnesses of Solemnization (2 x RM20.00) : RM 40.00

—————
total : RM 155.00
—————
Sel. P.U. 19. 138
First Schedule
form 4b
[Section 26]

enactment 2003
Declaration of Certificate of Marriage
Registration No.: ......................................................... Date of Register: .....................................
Marriage Approval No.: .................................................................................................................
Section: ..........................................................................................................................................
A. particulars of spouse
husband
Name: .............................................................................................................................................
Identity Card/Passport No.: .................................................................... Age: ..............................
Nationality: ..................................................................................................Race: ........................
Address: .........................................................................................................................................
........................................................................................................................................................
wife
Name: .............................................................................................................................................
Identity Card/Passport No.: ........................................................................ Age: .........................
Nationality: ..................................................................................................... Race: ....................
Address: .........................................................................................................................................
........................................................................................................................................................
b. particulars of wali
Name of Wali: ...............................................................................................................................
Relationship: ..................................................................................................................................
Address: .........................................................................................................................................
........................................................................................................................................................
139 Sel. P.U. 19.
C. particulars of witness
first witness
Name: .............................................................................................................................................
Address: .........................................................................................................................................
second witness
Name: .............................................................................................................................................
Address: .........................................................................................................................................
........................................................................................................................................................
d. particulars of marriage
Date of Solemnization Hijrah: .................................. Day: ...................... Time: .........................

Masihi
Place: ..............................................................................................................................................
Name of Registrar/Assistant Registrar: ..........................................................................................
No. of Marriage: ......................................... time(s) Wife No.: ....................................................
Mas Kahwin: RM ..................................................................................................... *Cash/Credit
Wedding Expenses: RM ................................................................................................................
Other gifts (If any): .......................................................................................................................
Date: ........................................ ................................................................

Signature of Registrar and Official Seal
E. declaration of ta’liq
The husband has stated ta’liq after the solemnization as follows:
“I declare that when I leave my wife for the duration of four consecutive months of Hijrah or more
deliberately or by force, or I or my representative does not provide for her lawful maintenance
for the said duration wherein she is loyal to me, or if I cause physical injury on her body,
where later she lodges a complaint to the Syariah Court and when the Syariah Court accept the
complaint, and she give to the Syariah Court, which received on my behalf an amount of TEN
RINGGIT, thereby causing the talaq upon her by way of Talaq Khul’ ”
Date: ........................................ ................................................................

Signature of Husband
Date: ........................................ ................................................................

Signature of Registrar and Official Seal
Sel. P.U. 19. 140
First Schedule
form 5

enactment 2003
Application for the Registration of Marriage

141 Sel. P.U. 19.
Sel. P.U. 19. 142
143 Sel. P.U. 19.
Sel. P.U. 19. 144
First Schedule
FORM 6A
[Subsection 43(1)]

ENACTMENT 2003
Application for Search in the Register
Application No.: ..........……………………………..................................…………………..………
Date of Application: ………………………………............................................…………….......
Type of Registration: ..................................................................................................................
information of marriage
Name of Wife: ……………………………………...........................................................................
Identity Card/Passport No.: ……………………………………................................................……
Name of Husband: …..………………………………….…...........................................……………
Identity Card/Passport No.: ...………………….………………................................................……
Date of Marriage: ..........................................................................................................................
Date of Divorce: ............................................................................................................................
Date of Rujuk: ...............................................................................................................................
Place of Marriage/Divorce/Rujuk: .................................................................................................
Signature of the Applicant:
……….……….....…………………………
(Name of Applicant)
Date: .........................................
145 Sel. P.U. 19.
First Schedule
FORM 6B
[Subsection 43(2)]

ENACTMENT 2003
Results of Search in the Register
Application No.: ..........……………………………..................................…………………..………
Date of Application: ………………………………............................................…………….......
Type of Registration: ..................................................................................................................
information of marriage
Wife’s Name: ………………………………..……...........................................................................
Identity Card/Passport No.: ……………………………………................................................……
Husband’s Name: …..…………...……………………….…...........................................……………
Identity Card/Passport No.: ...………………….………………................................................……
Date of Marriage: ..........................................................................................................................
Date of Divorce: ............................................................................................................................
Date of Rujuk: ...............................................................................................................................
Place of Marriage/Divorce/Rujuk: .................................................................................................
It is certified that the search has been conducted in the register and the results are as follows:
........................................................................................................................................................
........................................................................................................................................................
........................................................................................................................................................
Particulars in the register (if any)
Name in the Register: ....................................................................................................................

Registration No.: ............................................................................................................................
Place of Registration: . ...................................................................................................................
Certified by:
……….……….....…………………………
Registrar
Date: .........................................
Sel. P.U. 19. 146
First Schedule
FORM 7A
[Subsection 52(2)]

ENACTMENT 2003
Application for Rujuk
To:
Registrar of Marriage, Divorce and Rujuk
District ……………………………..................................………
1. informations of husband
Name: .......................................................................................................................................
Identity Card/Passport No.: ......................................................................................................
Date of Birth: ............................................... Nationality: .......................................................
Race: .........................................................................................................................................
Address (Home): ......................................................................................................................
...................................................................................................................................................
Occupation: ...............................................................................................................................
Telephone No.: (H) ................................ (O) ................................. (H/P) ...........................
2. Informations of wife
Name: .......................................................................................................................................
Identity Card/Passport No.: ......................................................................................................
Date of Birth: ............................................... Nationality: .......................................................
State/Country of Origin: ...........................................................................................................
Race: .........................................................................................................................................
Address (Home): ......................................................................................................................
...................................................................................................................................................
Occupation: ...............................................................................................................................
Telephone No.: (H) ................................ (O) ................................. (H/P) ..........................

147 Sel. P.U. 19.
3. Informations of divorce
Date of Divorce: ...................................... Day: .......................... Time: ...............................

Type of Talaq: .................................... For the: ................... time. Total: .............................
Divorce *outside/inside of the Court. Mal Case No.: ...........................................................
Date of Previous Rujuk: (If any): ............................................................................................
4. declaration of husband
I (name of husband) ................................................................................................................

Have rujuk my wife on ............................... with lafaz ..........................................................
5. declaration of wife
I (name of wife) ......................................................................................................................

consent to rujuk with my divorced husband (name of husband) .............................................
and when I rujuk with him, I am still in ‘iddah. The date of my ‘iddah will end ................
6. pronouncement of rujuk by husband
I (name of husband) .................................................................................................................

rujuk with my wife (name of wife) .........................................................................................
to my previous marriage ..........................................................................................................
Date of rujuk pronouncement: .................................................................................................
7. comment of registrar
...................................................................................................................................................
..................................................................................................................................................
......................................................... ...............................................................
Signature of Husband Signature of Wife
(If Present)
In the presence of:

........................................................................
Signature of Registrar/Official Seal/Date
Please attach:
1. A copy of husband and wife’s identity card.
2. Divorce application registration receipt at the Syariah Court or results of hearing from
the Syariah Court (if any).
Sel. P.U. 19. 148
First Schedule
FORM 7b
[Subsection 52(3)]

ENACTMENT 2003
Declaration of Rujuk Certificate
Rujuk Registration No.: ............................................... Date: Hijrah ...................

Masihi
A. informations of couple
1. Name of Husband: ....................................................................................................................

Identity Card/Passport No.: .............................................. Date of Birth: ..............................
Race: .................................................................................... Nationality: ...............................
Address (Home): ......................................................................................................................
...................................................................................................................................................
Date of conversion to Islam (If mualaf): .............. Declaration of Islam Card No.: ..............
2. Name of Wife: ..........................................................................................................................

Identity Card/Passport No.: ............................................... Date of Birth: ............................
Race: ......................................................................................Nationality: ...............................
Address (Home): ......................................................................................................................
...................................................................................................................................................
Date of conversion to Islam (If mualaf): .............. Declaration of Islam Card No.: ..............
B. pronouncement of rujuk
I ...................................................................................................................... pronounce that:

(Name of Registrar)
(Name of Husband) .......................................................................................... has rujuk with

his wife (Name of Wife) ..................................................................................................... by
saying: “I rujuk with my wife ................................................................................ to my
previous solemnization (date of the solemnization) ...............................................................”
c. general information
Date of Rujuk: Hijrah ..................... Frequency of Rujuk: ....................................

Masihi
Date of Solemnization: Hijrah ..................... Solemnization Registration No.: ..................
Masihi
Date of Divorce: Hijrah ..................... Divorce Registration No.: ............................
Masihi
Other information: ....................................................................................................................
Date: Hijrah ......................................... ..........................................................................

Masihi Signature of Registrar of Marriage
and Official Seal
149 Sel. P.U. 19.
First Schedule
Form 8
[Subsection 55(5)]
Islamic family law (state of selangor)

Enactment 2003
Declaration of Divorce Certificate
1. Divorce Registration No.: ......................................................................................................

2. Declaration of Solemnization Registration No.: ....................................................................
3. Declaration of Rujuk Registration No.: .................................................................................
4. Mal Case No.: . ......................................................................................................................
5. Date of Solemnization: Hijrah ......................................
Masih
6. Date of Rujuk: Hijrah . ...................................................
Masihi
7. Place of Solemnization: District: ............................. State/Country: . ..................................
8. Name of Husband: .................................................................................................................
Identity Card/Passport No.: . ...................................... Race: ............................................
Date of Birth: .......................................................... Nationality:.........................................
Address (Home):.....................................................................................................................
Occupation: ............................................................................................................................
9. Name of Wife: .......................................................................................................................
Identity Card/Passport No.: . ...................................... Race: ............................................

Date of Birth: .......................................................... Nationality..........................................
Address (Home):.....................................................................................................................
Occupation: ............................................................................................................................
10. Type of Divorce: *Raj’ie/Bain (Bain Sughra/Bain Kubra/Bain Muabbad)
No. of Talaq: . .......................................................... Total No. of Talaq: . ..........................
Payment for Talaq Khul’ (If any): . .......................................................................................
Manner of Divorce: *With Permission of the Court/Without Permission of the Court
Place of Divorce: ...................................................................................................................
Date of Divorce: Hijrah ................................................
Masihi
Divorce during *Non-Menstrual Period/Menstrual/Pregnancy: . ............................................
Other information: . ........................................................................................................................

........................................................................................................................................................
........................................................................................................................................................
Date: Hijrah ........................................... . .........................................................

Masihi Signature of Registrar and
Official Seal

Sel. P.U. 19. 150
Second Schedule
Fee
Islamic Family law (state of selangor)

enactment 2003
no. subject rate
1. Permission to marry within/out of the State of Selangor RM10.00

(Male)
(Sec. 17)
2. Permission to marry within/out of the State of Selangor RM10.00

(Female)
(Sec. 17)
3. Declaration of Marriage Certificate RM20.00

(Sec. 26)
4. Copy of Declaration of Marriage Certificate RM20.00

(Sec. 26)
5. Marriage, Divorce and Rujuk Registration Search RM10.00

(Sec. 43)
6. Declaration of Divorce Certificate RM20.00

(Subsec. 55(5))
7. Copy of Declaration of Divorce Certificate RM25.00

(Subsec. 55(5))
8. Declaration of Rujuk Certificate RM10.00

(Subsec. 52(3))
9. Copy of Declaration of Rujuk Certificate RM10.00

(Subsec. 52(3))
Made 11 August 2009

[JAI.Sel.BUUK 02/006/Jld. 6; P.U. Sel. Am 0110/08/TS]
Dato’ Setia Haji Mohamad Adzib bin Mohd Isa

Chairman
Majlis Agama Islam Selangor
151 Sel. P.U. 20.
19.
Sel. P.U. 20.

Akta Pengangkutan Jalan 1987
(Akta 333)
Perintah Had Laju Tempatan (Jalan Negeri) (Larangan Masa
Tertentu) (No. 2) 2009
P ada menjalankan kuasa yang diberikan oleh subseksyen 69(2) Akta

Pengangkutan Jalan 1987 [Akta 333], Kerajaan Negeri Selangor membuat
perintah yang berikut:
Nama dan permulaan kuat kuasa
1. (1) Perintah ini bolehlah dinamakan Perintah Had Laju Tempatan (Jalan
Negeri) (Larangan Masa Tertentu) (No. 2) 2009.
(2) Perintah ini mula berkuat kuasa dari 13 September 2009 hingga
27 September 2009.
Larangan
2. (1) Pemanduan kenderaan motor dengan kelajuan lebih daripada 80 km/j

di jalan negeri di Negeri Selangor, selain daripada jalan yang ditetapkan had
laju 60 km/j, 70 km/j dan 80 km/j yang dinyatakan dalam senarai kepada
Perintah Had Laju Tempatan (Jalan Negeri) (Selangor Darul Ehsan) 1993
[Sel. P.U. 27/1993], adalah dilarang.
(2) Larangan yang disebut dalam subperenggan (1) hendaklah terhenti

berkuat kuasa apabila habis tempoh Perintah ini.
Bertarikh 9 September 2009

[P.U. Sel. Am 0076/1 Jld. 4]
Mohamad Yasid bin Bidin

Setiausaha
Majlis Mesyuarat Kerajaan Negeri
Selangor
Road Transport Act 1987

(Act 333)
Local Speed Limit (State Roads) (Specified Time Prohibition)
(No. 2) Order 2009
In exercise of the powers conferred by subsection 69(2) of the Road Transport

Act 1987 [Act 333], the State Government of Selangor makes the following
order:
Citation and commencement
1. (1) This order may be cited as the Local Speed Limit (State Roads)
(Specified Time Prohibition) (No. 2) Order 2009.
Sel. P.U. 19.
20. 152
(2) This Order comes into operation from 13 September 2009 until
27 September 2009.
Prohibition
2. (1) The driving of motor vehicles at a speed exceeding 80 km/h on state

roads in the State of Selangor, other than the roads which is the speed limit
of 60 km/h, 70 km/h and 80 km/h specified in the list of the Local Speed
Limit (State Roads) (Selangor Darul Ehsan) Order 1993 [Sel. P.U. 27/1993],
is prohibited.
(2) The prohibition mentioned in subparagraph (1) shall cease to have

effect upon the expiry of this Order.
Dated 9 September 2009

[P.U. Sel. Am 0076/1 Jld. 4]
Mohamad Yasid bin Bidin

Clerk
State Executive Council
Selangor
Hakcipta Pencetak H
PERCETAKAN NASIONAL MALAYSIA BERHAD
Semua Hak Terpelihara. Tiada mana-mana bahagian jua daripada penerbitan ini boleh diterbitkan semula atau disimpan di dalam bentuk
yang boleh diperolehi semula atau disiarkan dalam sebarang bentuk dengan apa jua cara elektronik, mekanikal, fotokopi, rakaman dan/
atau sebaliknya tanpa mendapat izin daripada Percetakan Nasional Malaysia Berhad (Pencetak kepada Kerajaan Malaysia yang
dilantik).
DICETAK OLEH
PERCETAKAN NASIONAL MALAYSIA BERHAD,
KUALA LUMPUR
BAGI PIHAK DAN DENGAN PERINTAH KERAJAAN MALAYSIA

Kaedah Kaedah Perkahwinan Cerai Dan Rujuk Borang Dan Fi 2009

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Kaedah Kaedah Perkahwinan Cerai Dan Rujuk Borang Dan Fi 2009

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NEGERI SELANGOR

GOVERNMENT OF SELANGOR GAZETTE

Jil. 62 TAMBAHAN No. 12

Sel. P.U. 19.

Kaedah-kaedah Perkahwinan, Cerai dan Rujuk

ENAKMEN UNDANG-UNDANG KELUARGA ISLAM

Kaedah-kaedah Perkahwinan, Cerai dan Rujuk

1. Kaedah-kaedah ini bolehlah dinamakan Kaedah-kaedah Perkahwinan,

4. Ketidakpatuhan dengan mana-mana borang yang ditetapkan tidak menyebabkan

6. Semua kaedah, perisytiharan, perintah, pemberitahuan, notis, borang, surat

ENAKMEN UNDANG-UNDANG KELUARGA ISLAM

Akuan Pengesahan Pemastautinan

A. TERMA DAN SYARAT PERMOHONAN:

1. Pemohon mestilah tinggal sekurang-kurangnya 4 bulan atau lebih di dalam Kariah di

2. Satu salinan kad pengenalan pemohon.

4. Pengesahan hendaklah dibuat oleh: Penghulu/Ketua Kampung/Pengerusi Jawatankuasa

2. No. Kad Pengenalan/Pasport: .........................................................................................................

3. Alamat dalam Kad Pengenalan/Pasport: . .......................................................................................

4. Alamat Kediaman: ..........................................................................................................................

5 No. Telefon: (R) ....................................(P) ..................................... (H/P) ...................................

6. Nama Masjid/Kariah: ....................................................Daerah: ...................................................

7. Tempoh menetap di Negeri Selangor: ................................Tahun ...................................... Bulan

Tarikh: Hijrah ................................................ .......................................................

2. No. Kad Pengenalan/Pasport: .........................................................................................................

3. Alamat kediaman: ...........................................................................................................................

Tarikh: Hijrah ........................................... ..........................................................

Saya ...................................................................No. Kad Pengenalan/Pasport: ...................

sebagai ..........................................................................................................setelah meneliti

diberikan oleh ................................................................................................... Oleh yang

Tarikh: Hijrah ......................................... ...................................................................

ENAKMEN UNDANG-UNDANG KELUARGA ISLAM

Permohonan Kebenaran Berkahwin (Lelaki)

2. No. Kad Pengenalan/Pasport: .............................................Warganegara: ..........................................

Tarikh Lahir: .................................................................Bangsa: .........................................................

Alamat (Rumah): ..................................................................................................................................

Kelulusan Akademik: . ..........................................................................................................................

Pekerjaan: ...................................................................... Pendapatan: .................................................

Alamat (Pejabat): .................................................................................................................................

No. Telefon: (R) ............................................(P) .....................................(H/P) ..................................

3. Saya memohon berkahwin dengan: ......................................................................................................

No. Kad Pengenalan/Pasport: ...............................................................................................................

Tarikh Lahir: ................................................................ Bangsa: ........................................................

Alamat (Rumah): ..................................................................................................................................

Kelulusan Akademik: . ..........................................................................................................................

Pekerjaan: .............................................................................. Pendapatan: ........................................

Alamat (Pejabat): ..................................................................................................................................

No. Telefon: (R) ...................................... (P) ................................. (H/P) ..........................................

beralamat di: .........................................................................................................................................

Nama Masjid/Kariah: ...................................................Daerah: ............................................

Negeri: ..........................................................Negara: ...........................................................

5. Saya ialah seorang *teruna/duda.

6. Saksi bagi pengesahan butiran diri pemohon ialah:

PENGAKUAN PEMOHON DAN SAKSI

Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................

Tarikh: Hijrah ………………………………. ..............................................................

ULASAN PENOLONG PENDAFTAR NIKAH

Tarikh: Hijrah …………………………. .........................................................................

ULASAN KETUA PENDAFTAR/PENDAFTAR

Permohonan *diluluskan/tidak diluluskan.

Tarikh: Hijrah …………………………. .........................................................................

* Potong yang tidak berkenaan.

ENAKMEN UNDANG-UNDANG KELUARGA ISLAM

Permohonan Kebenaran Berkahwin (Poligami)