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SURAT PERNYATAAN
Yang membuat pernyataan dibawah ini :
:
:
:
:
:
:
:

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

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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
Saksi I
Nama
Umur
Pekerjaan
Alamat

(materai
Rp. 6000,00,-)

:
:
:
:

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Tanda tangan
Saksi II
Nama
Umur
Pekerjaan
Alamat

:

___________________________________________

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

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

___________________________________________

:
:
:
:

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Mengetahui,
Kepala KUA Kec. Dolopo

................................................ Nama : .................................................................... Kepala KUA Kec...................................................................................... Tanda tangan Saksi II Nama Umur Pekerjaan Alamat : ___________________________________________ Mengetahui........................ .................................................................. yang ada di Buku Nikah No.............................................................................................................................................................../Kel.................................................................................................................................................................................................................................................... .............................................................. 6000... ................. Nama : ................................. KTP .................................. tgl................................................................................................... yang ada di ...................................................................................................... ................................... Nama : ........................................................................................................................................................................................ lahir Jenis Kelamin Agama Pekerjaan Alamat No............................................................................................................................................................................................ SURAT PERNYATAAN Yang membuat pernyataan dibawah ini : : : : : : : : Nama Tempat............................................................................................................................................................................................................com/ to remove this watermark...........................................................................................................................................00....................................................................................................................................................... adalah satu orang.............................................. yang ada di Surat Kelahiran No..................................................................................................................................................................... yang ada di Ijazah No.......................................... ............................................................................................................................................ ......................................................................................... .............................................. Nama : .......................................................................... ......................... ................................................ 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.............................................................................................................................................................................................................................................. ............ 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..................................................................................................................... ................ ............... saya sertakan para saksi yang mengetahui nama-nama tersebut................................ ................................................................................................................................................................... ..................................................................................................... ...................................................................................................................................................................................................................................................................................................................... Adapun yang dipergunakan dalam Akta / Kutipan Akta Kelahiran ialah Nama : .................................................... Kepala Ds.............................................................................................................................................................................................................................................................................................................. Madiun....................................................................Please purchase PDFcamp Printer on http://www.........verypdf........................... Yang menyatakan Saksi I Nama Umur Pekerjaan Alamat (materai Rp................................... ................................ yang ada di KTP No................................................................................... ............................................................... Mengetahui...................................... Dolopo .................................. ............................................. ..................................................-) : : : : .............................................. ..................................................................................................................... ...................................................................................................................................... Untuk menguatkan penyataan yang saya buat................................................................................................ yang ada di KK No.................................................................. ___________________________________________ : : : : ..................................................................................................................................

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