Surat Pernyataan Beda Nama Baru 2011

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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 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

:

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

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

Tanda tangan

:

___________________________________________

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

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

Saksi II

___________________________________________

Nama

:

Umur

:

Pekerjaan Alamat

: :

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

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

Mengetahui, Kepala KUA Kec. Dolopo

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

:

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

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

Tanda tangan

:

___________________________________________

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

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

Saksi II

___________________________________________

Nama

:

Umur

:

Pekerjaan Alamat

: :

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

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

Mengetahui, Kepala KUA Kec. Dolopo