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
:
PERUBAHAN NAMA
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
PERUBAHAN NAMA
30
1.Nama Lama:
...................................................................................
31
2.Nama Baru:
...................................................................................
32
3.Nomor Akta kelahiran:
...................................................................................
33
4.Nama Ayah/Ibu/Wali:
...................................................................................
34
(bagi yang dibawah umur)
35
5.NIK Nama Ayah/Ibu/Wali:
...................................................................................
36
6.Kewarganegaraan:
...................................................................................
37
7.Nomor Penetapan Pengadilan:
...................................................................................
38
8.Tanggal Penetapan Pengadilan:Tgl :Bln :Thn :
39
9.Nama Lembaga Pengadilan:
...................................................................................
40
41
42
…...................., …...................20...…..
43
Mengetahui ;Pelapor,
44
Kepala Desa/Lurah,
45
46
47
48
49
(…...............................................)(…...............................................)
50
51
52
53
54
55
56
57
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