ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAE
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Provinsi
:
BALI
F-2.01
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Kabupaten/Kota
:
BULELENG
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Kecamatan
:
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Desa/Kelurahan
:
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Kode Wilayah
:
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FORMULIR PELAPORAN PENCATATAN SIPIL DIDALAM WILAYAH NKRI
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Jenis Pelaporan Pencatatan Sipil
:
PENGESAHAN ANAK
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DATA PELAPOR
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Nama
:
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NIK:
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Nomor Dokumen Perjalanan *
:
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Nomor Kartu Keluarga
:
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Kewarganegaraan
:
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DATA SAKSI I
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Nama
:
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NIK:
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Nomor Kartu Keluarga
:
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Kewarganegaraan
:
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DATA SAKSI II
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Nama
:
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NIK:
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Nomor Kartu Keluarga
:
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Kewarganegaraan
:
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PENGAKUAN ANAK
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1.Nomor Akta Kelahiran:
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2.Tanggal/Bulan/Tahun:Tgl :Bln :Thn :
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Penerbitan Akta Kelahiran
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3.Dinas Kabupaten/Kota yang:
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Menerbitkan Akta Kelahiran
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4.Tanggal/Bulan/Tahun:Tgl :Bln :Thn :
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Kelahiran Anak
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5.Tanggal/Bulan/Tahun:Tgl :Bln :Thn :
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Perkawinan Agama
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6.Nomor Tanggal/Bulan/Tahun:Tgl :Bln :Thn :
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Akta Perkawinan/Buku Nikah
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7.Nama Ibu Kandung:
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8.NIK Ibu Kandung:
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9.Kewarganegaraan Ibu Kandung:
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10.Nama Ayah Kandung:
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11.NIK Ayah Kandung:
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12.Kewarganegaraan Ayah Kandung:
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13.Nomor Penetapan Pengadilan:
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14.Tanggal Penetapan Pengadilan:Tgl :Bln :Thn :
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15.Nama Lembaga Pengadilan:
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…...................., …...................20...…..
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Mengetahui ;Pelapor,
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Kepala Desa/Lurah,
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(…...............................................)(…...............................................)
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