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Surat Pernyataan Beda Nama Baru 2011

Surat Pernyataan Beda Nama Baru 2011

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Published by: Fathony Tony on Feb 15, 2012
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SURAT PERNYATAAN

Yang membuat pernyataan dibawah ini :

Nama :
.....................................................................................................................................................................................................................................................................................
Tempat, tgl. lahir :
.....................................................................................................................................................................................................................................................................................
Jenis Kelamin :
.....................................................................................................................................................................................................................................................................................
Agama :
.....................................................................................................................................................................................................................................................................................
Pekerjaan :
.....................................................................................................................................................................................................................................................................................
Alamat :
.....................................................................................................................................................................................................................................................................................
No. KTP :
.....................................................................................................................................................................................................................................................................................

Dengan ini menyatakan dengan sebenarnya bahwa :

Nama :
...........................................................................................................................................................
yang ada di Buku Nikah No. ...................................................................................................
Nama :
...........................................................................................................................................................
yang ada di KTP No. .....................................................................................................................................
Nama :
...........................................................................................................................................................
yang ada di KK No. .......................................................................................................................................
Nama :
...........................................................................................................................................................
yang ada di Ijazah No. ..........................................................................................................................
Nama :
...........................................................................................................................................................
yang ada di Surat Kelahiran No. .....................................................................................
adalah satu orang.
Adapun yang dipergunakan dalam Akta / Kutipan Akta Kelahiran ialah
Nama : ....................................................................................................................................................... yang ada di ...................................................................................................................................................................

Untuk menguatkan penyataan yang saya buat, saya sertakan para saksi yang mengetahui
nama-nama tersebut.

Demikian Surat pernyataan ini saya buat dengan sebenarnya dan apabila dikemudian hari
pernyataan saya ini tidak sesuai/tidak benar saya berikut para saksi bertanggung jawab terhadap
semua akibat hukum yang timbul, tidak akan melibatkan Pejabat yang ikut menanda tangani
pernyataan ini dan kami sanggup dituntut dihadapan hakim sesuai dengan hukum yang berlaku.


Madiun, .........................................................................................
Yang menyatakan

(materai
Rp. 6000,00,-)



___________________________________________


Saksi I
Nama :
.......................................................................................................................................

Umur :
.......................................................................................................................................

Pekerjaan :
.......................................................................................................................................
Alamat :
.......................................................................................................................................

.......................................................................................................................................
Mengetahui,
Kepala Ds./Kel. ..............................................................



___________________________________________

Tanda tangan :
.......................................................................................................................................




Saksi II

Nama :
.......................................................................................................................................
Umur :
.......................................................................................................................................
Mengetahui,
Kepala KUA Kec. Dolopo




Pekerjaan :
.......................................................................................................................................


Alamat :
.......................................................................................................................................



.......................................................................................................................................


Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.
SURAT PERNYATAAN

Yang membuat pernyataan dibawah ini :

Nama :
.....................................................................................................................................................................................................................................................................................
Tempat, tgl. lahir :
.....................................................................................................................................................................................................................................................................................
Jenis Kelamin :
.....................................................................................................................................................................................................................................................................................
Agama :
.....................................................................................................................................................................................................................................................................................
Pekerjaan :
.....................................................................................................................................................................................................................................................................................
Alamat :
.....................................................................................................................................................................................................................................................................................
No. KTP :
.....................................................................................................................................................................................................................................................................................

Dengan ini menyatakan dengan sebenarnya bahwa :

Nama :
...........................................................................................................................................................
yang ada di Buku Nikah No. ...................................................................................................
Nama :
...........................................................................................................................................................
yang ada di KTP No. .....................................................................................................................................
Nama :
...........................................................................................................................................................
yang ada di KK No. .......................................................................................................................................
Nama :
...........................................................................................................................................................
yang ada di Ijazah No. ..........................................................................................................................
Nama :
...........................................................................................................................................................
yang ada di Surat Kelahiran No. .....................................................................................
adalah satu orang.
Adapun yang dipergunakan dalam Akta / Kutipan Akta Kelahiran ialah
Nama : ....................................................................................................................................................... yang ada di ...................................................................................................................................................................

Untuk menguatkan penyataan yang saya buat, saya sertakan para saksi yang mengetahui
nama-nama tersebut.

Demikian Surat pernyataan ini saya buat dengan sebenarnya dan apabila dikemudian hari
pernyataan saya ini tidak sesuai/tidak benar saya berikut para saksi bertanggung jawab terhadap
semua akibat hukum yang timbul, tidak akan melibatkan Pejabat yang ikut menanda tangani
pernyataan ini dan kami sanggup dituntut dihadapan hakim sesuai dengan hukum yang berlaku.


Madiun, .........................................................................................
Yang menyatakan

(materai
Rp. 6000,00,-)



___________________________________________


Saksi I
Nama :
.......................................................................................................................................

Umur :
.......................................................................................................................................

Pekerjaan :
.......................................................................................................................................
Alamat :
.......................................................................................................................................

.......................................................................................................................................
Mengetahui,
Kepala Ds./Kel. ..............................................................



___________________________________________

Tanda tangan :
.......................................................................................................................................




Saksi II

Nama :
.......................................................................................................................................
Umur :
.......................................................................................................................................
Mengetahui,
Kepala KUA Kec. Dolopo




Pekerjaan :
.......................................................................................................................................


Alamat :
.......................................................................................................................................



.......................................................................................................................................


Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

....................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................ saya sertakan para saksi yang mengetahui nama-nama tersebut.......................................................................................................... Adapun yang dipergunakan dalam Akta / Kutipan Akta Kelahiran ialah Nama : ........................................... yang Nama : .................................................................................................................................................................................................................................................. ...................................... ............................................................................................................................................................................................................................................................ tgl...................................................... Dengan ini menyatakan dengan sebenarnya bahwa : Nama : ............................................. tidak akan melibatkan Pejabat yang ikut menanda tangani pernyataan ini dan kami sanggup dituntut dihadapan hakim sesuai dengan hukum yang berlaku..................................................................................................................................................................................................... ....................................................................... yang adalah satu orang........... lahir Jenis Kelamin Agama Pekerjaan Alamat No........ ...................................................................................... Yang menyatakan Saksi I Nama Umur Pekerjaan Alamat (materai Rp........................... .......................................... yang Nama : ....................................................................com/ to remove this watermark. .....................................verypdf............................................................................................................ KTP : : : : : : : ...................................................................................... ................................................................... ada di KTP No........................................................................................................... ada di Ijazah No. ............................. Mengetahui.............................................................................................................................................................................................................................................................................................................................................../Kel.................................................................................................................................................... ............ ...................................................................................................................................................................................................................................... yang ada di ............................. yang Nama : ............................................................................................................. ....................................................................................................................................................................................... 6000.... Madiun......................................................................................................................................................................................................................................................Please purchase PDFcamp Printer on http://www.................................................... Kepala KUA Kec................................................................................................................................................................... ada di KK No.................................................................................00................................................................................................................................................................... ...................................................................... ada di Buku Nikah No.............. yang Nama : ....................... ................................................................................................ Tanda tangan Saksi II Nama Umur Pekerjaan Alamat : ................... .... ................................................... ___________________________________________ Mengetahui........ SURAT PERNYATAAN Yang membuat pernyataan dibawah ini : Nama Tempat.... ada di Surat Kelahiran No.............................................................. ..................................................................................................................................................................................................... Untuk menguatkan penyataan yang saya buat.................................................................. ........................... ___________________________________________ : : : : ...................................................................... Dolopo ....................................................................................................................................-) : : : : .............................................................................. .................................................................................................................. Demikian Surat pernyataan ini saya buat dengan sebenarnya dan apabila dikemudian hari pernyataan saya ini tidak sesuai/tidak benar saya berikut para saksi bertanggung jawab terhadap semua akibat hukum yang timbul.......................................................................................................... ...... .................................................................................... Kepala Ds.................

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