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
:
PEMBETULAN AKTA PENCATATAN SIPIL
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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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PEMBETULAN AKTA PENCATATAN SIPIL
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1.
Nomor Akta yang akan dibetulkan/
:
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ditarik
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2.Nama Ayah/Ibu/Wali:
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(yang dibawah umur)
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3.NIK ayah/ibu/wali:
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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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