INDONESIAN IDENTITY CARD

PROVINCE OF SOUTH SUMATRA

CITY OF PALEMBANG

Single Identity Number : 16xxxxxxxxxx08

Full Name : HARYADI YANSYAH
Place, Date of Birth : PALEMBANG, xx-xx-19xx
Sex : MALE Blood Type : -
Addres : SILAxxxxxxxxx STREET
Neighborhood Ward (RT/RW) : 0xx/0xx
Village Administrative Unit : xxxxx
Sub-District : xxxxx
Religion : ISLAM
Marital Status : SINGLE
Occupation : STUDENT*
Nationality : INDONESIAN CITIZEN
Validity : xx-xx-2017*

CITY OF PALEMBANG
3/28/2012

---signed of---

HARYADI YANSYAH

PS:
* Student is my occupation when this ID Card was made March 28, 2012.
*Based to the Law of the Republic of Indonesia Number 24/2013 as stipulated in Article 64
paragraph 7a which mandates e-ID card lifetime validity, all E-ID card is valid for life even if
there is expiry date (Validity).
 TRANSLATION

STATE EMBLEM
FAMILY IDENTITY CARD
No. 167xxxxxxx0
Head of Family : Drs. H. Xxxxxxx Sub-District : SEBxxxxxx
Address : SILAxxxxxxxxxx STREET City : PALEMBANG
Neighborhood ward (RT/RW) : 0xx/0xx Post Code : 30xxx
Village Administrative Unit : SILAxxxxxxxxxx Province : SOUTH SUMATRA

No. Full Name Single Identity Number Sex Place of Birth Date of Birth Religion Education Occupation
(1) (2) (3) (4) (5) (6) (7) (8)
1 DRS. H.xxxxxxxxx 167xxxxxxxxxxxxxxxxx MALE PALEMBANG xx-xx-19xx ISLAM BACHELOR'S DEGREE ENTREPRENEUR
2 HJ. Sxxxxxx 167xxxxxxxxxxxxxxxxx FEMALE PALEMBANG xx-xx-19xx ISLAM SENIOR HIGH SCHOOL HOUSE WIFE
3 HARYADI YANSYAH 167xxxxxxxxxxxxxxxxx MALE PALEMBANG xx-xx-19xx ISLAM SENIOR HIGH SCHOOL STUDENT
4 M.AGUS xxxxxxxxxxxx 167xxxxxxxxxxxxxxxxx MALE PALEMBANG xx-xx-19xx ISLAM JUNIOR HIGH SCGOOL STUDENT
5 ARIYANSA xxxxxxxxxxx 167xxxxxxxxxxxxxxxxx MALE PALEMBANG xx-xx-19xx ISLAM ELEMENTARY SCHOOL STUDENT
6 - - - - - - - -
7 - - - - - - - -
8 - - - - - - - -
9 - - - - - - - -
10 - - - - - - - -

Immigration Document Parent's Name

No. Marital Status Relation Nationality
Passport No. KITAP No. Father Mother
(9) (10) (11) (12) (13) (14) (15)
1 MARRIED HEAD OF FAMILY INDONESIA - - Abxxxxxxxxx AISxxxxxxxxx
2 MARRIED WIFE INDONESIA - - Maxxxxx NURxxxxxxxx
3 NOT MARRIED CHILD INDONESIA - - HASxxxxxxxxxxx SYAxxxxxxxxx
4 NOT MARRIED CHILD INDONESIA - - HASxxxxxxxxxxx SYAxxxxxxxxx
5 NOT MARRIED CHILD INDONESIA - - HASxxxxxxxxxxx SYAxxxxxxxxx
6 - - - - - - -
7 - - - - - - -
8 - - - - - - -
9 - - - - - - -
10 - - - - - - -

Issued Date : xx-xx-20xx Head of Sub-District

Copy : I. Head of Family Head of Family Seberang Ulu I
II. Neighborhood ward
III. Village Administrative Unit ---signed--- ---signed---
IV. Sub District
DRS.H.xxxxxxxxx DRS.H.M.xxxxxxxxxxxxxxx
(Signature/Fingerprint) NIP.19700xxxxxxxxxxxxxxxxxx001