ABCDEFGHIJKLMNOPQRSTUVWXYZAAABACADAE
1
2
Provinsi
:
BALI
F-2.01
3
Kabupaten/Kota
:
BULELENG
4
Kecamatan
:
5
Desa/Kelurahan
:
6
Kode Wilayah
:
7
8
FORMULIR PELAPORAN PENCATATAN SIPIL DIDALAM WILAYAH NKRI
9
Jenis Pelaporan Pencatatan Sipil
:
PENGANGKATAN ANAK
10
11
DATA PELAPOR
12
Nama
:
...................................................................................
13
NIK:
...................................................................................
14
Nomor Dokumen Perjalanan *
:
...................................................................................
15
Nomor Kartu Keluarga
:
...................................................................................
16
Kewarganegaraan
:
...................................................................................
17
18
DATA SAKSI I
19
Nama
:
...................................................................................
20
NIK:
...................................................................................
21
Nomor Kartu Keluarga
:
...................................................................................
22
Kewarganegaraan
:
...................................................................................
23
DATA SAKSI II
24
Nama
:
...................................................................................
25
NIK:
...................................................................................
26
Nomor Kartu Keluarga
:
...................................................................................
27
Kewarganegaraan
:
...................................................................................
28
29
PENGANGKATAN ANAK
30
1.Nama anak angkat:
...................................................................................
31
2.Nomor Akta Kelahiran:
...................................................................................
32
3.Tanggal/Bulan/Tahun:Tgl :Bln :Thn :
33
Penerbitan Akta Kelahiran
34
4.Dinas Kabupaten/Kota yang:
...................................................................................
35
Menerbitkan Akta Kelahiran
36
5.Nama Ibu Kandung:
...................................................................................
37
6.NIK Ibu Kandung:
...................................................................................
38
7.Kewarganegaraan:
...................................................................................
39
8.Nama Ayah Kandung:
...................................................................................
40
9.NIK Ayah Kandung:
...................................................................................
41
10.Kewarganegaraan :
...................................................................................
42
11.Nama Ibu Angkat:
...................................................................................
43
12.NIK Ibu Angkat:
...................................................................................
44
13.Nomor Paspor:
...................................................................................
45
14.Nama Ayah Angkat:
...................................................................................
46
15.NIK Ayah Angkat:
...................................................................................
47
16.Nomor Paspor:
...................................................................................
48
17.Nama Pengadilan:
...................................................................................
49
18.Tanggal Penetapan Pengadilan:Tgl :Bln :Thn :
50
19.Nomor Penetapan Pengadilan:
...................................................................................
51
20.
Nama Lembaga Penetapan Pengadilan
:
...................................................................................
52
21.
Tempat Lembaga Penetapan Pengadilan
:
...................................................................................
53
54
55
…...................., …...................20...…..
56
Mengetahui ;Pelapor,
57
Kepala Desa/Lurah,
58
59
60
61
62
(…...............................................)(…...............................................)
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100