Lampiran 26 PMA No.

2 Tahun 1990
Pasal 31 Ayat (1)

Model DN

DUPLIKAT KUTIPAN AKTA NIKAH

Kk.14.04.12/PW.01/521/2013
Nomor : ....................................................
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500/04 /III/1996
Tanggal : 04 MARET 1996
................................................................................................
JUMAT
................................................................................................
16 FEBRUARI 1996
................................................................................................
21.00
................................................................................................

Ayah
Ibu

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ERWANDI ---------------------------------------------------------------................................................................................................
KETAPANG, 21 TAHUN
................................................................................................
INDONESIA
................................................................................................
ISLAM
................................................................................................
SWASTA
................................................................................................
DESA SUNGAI AWAN KANAN
................................................................................................
-----------------------------------------------------------------------------................................................................................................
JEJAKA
................................................................................................
SAIPULLAH
................................................................................................
MARIATON
................................................................................................

Ayah
Ibu

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RUMILAH----------------------------------------------------------------................................................................................................
KETAPANG,TAHUN 1975
................................................................................................
INDONESIA
................................................................................................
ISLAM
................................................................................................
SWASTA
................................................................................................
DESA SUNGAI AWAN KIRI
................................................................................................
-----------------------------------------------------------------------------................................................................................................
PERAWAN
................................................................................................
MUHAMMAD ARBI
.
HASIDAH
................................................................................................

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NASAB
................................................................................................
AYAH KANDUNG
................................................................................................
MUHAMMAD ARBI
................................................................................................
-----------------------------------------------------------------------------................................................................................................
KETAPANG, TAHUN 1949
................................................................................................
INDONESIA
................................................................................................
ISLAM
................................................................................................
TANI
................................................................................................
DESA SUNGAI AWAN KIRI
................................................................................................

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SEBENTUK CINCIN EMAS

................................................................................................
TUNAI
................................................................................................

------------------------------------------------------------------------------................................................................................................

YA
................................................................................................

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------------------------------------------------------------------------------................................................................................................
------------------------------------------------------------------------------................................................................................................

Akta Nikah Nomor /Tanggal

I.
Telah dilangsungkan akad nikah
pada hari, tanggal, bulan, tahun (hijriyah /
masehi) dan pukul
II.

III.

SUAMI
1. Nama lengkap dan alias
2. Tempat dan tanggal lahir
3. Warga negara
4. Agama
5. Pekerjaan
6. Tempat tinggal
7. Pendidikan terakhir
8. Status sebelum menikah
9. Orang tua kandung
ISTRI
1. Nama lengkap dan alias
2. Tempat dan tanggal lahir
3. Warga negara
4. Agama
5. Pekerjaan
6. Tempat tinggal
7. Pendidikan terakhir
8. Status sebelum menikah
9. Orang tua kandung

IV. WALI NIKAH

1. Status wali (nasab/hakim)
2. Hubungan wali / sebab
3. Nama lengkap dan alias
4. Bin
5. Tempat dan tanggal lahir
6. Warga negara
7. Agama
8. Pekerjaan
9. Tempat tinggal
V.

MASKAWIN
1. Berupa dan berapa
2. Pembayaran (tunai/hutang)

VI. PERJANJIAN PERKAWINAN

Jika ada perjanjian sebutkan
V.

TAKLIK TALAK
Sesudah akad nikah suami membaca dan
menandatangani taklik talak (ya/tidak)

VI. Jika Pencatatan Nikah Berdasarkan

putusan pengadilan, sebutkan :
1. Pengadilan yang memutuskan
2. Nomor dan tanggal keputusan

29 Oktober 2013
Ketapang, .......................................
Dikutip sebagai Duplikat sesuai dengan Akta Nikahnya
Yang mengutip Pegawai Pencatat Nikah
KECAMATAN DELTA PAWAN
KUA ..................................................

H. M. SYAFIIE, S.AG
.....................................................
197505202000031001
NIP. ........................................

Lampiran 26 PMA No. 2 Tahun 1990

Pasal 31 Ayat (1)

Model DN

DUPLIKAT KUTIPAN AKTA NIKAH

Kk.14.04.12/PW.01/73/2013
Nomor : ....................................................
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116 Tanggal : Oktober 1970

................................................................................................
................................................................................................
Oktober 1970 M
................................................................................................
................................................................................................

Ayah
Ibu

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ZAMHURI --------------------------------------------------------------................................................................................................
KALINILAM, 25 TAHUN
................................................................................................
INDONESIA
................................................................................................
ISLAM
................................................................................................
TANI
................................................................................................
KALINILAM
................................................................................................
................................................................................................
JEJAKA
................................................................................................
MUHAMAD
................................................................................................
AYU RABAYA
................................................................................................

Ayah
Ibu

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MASTINA
................................................................................................
----------------------------------------------------------------KP.TENGAH,
................................................................................................
19 TAHUN
................................................................................................
INDONESIA
................................................................................................
ISLAM
................................................................................................
TANI
................................................................................................
KP.SAMPIT
................................................................................................
................................................................................................
PERAWAN
.
UTI AMRI
................................................................................................
JAINIAH

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................................................................................................
HAKIM
................................................................................................
................................................................................................
H.HASAN ZULKIFLI
................................................................................................
................................................................................................
................................................................................................
................................................................................................
................................................................................................
................................................................................................

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................................................................................................
RP.25
................................................................................................
TUNAI

................................................................................................
-------------------------------------------------------------------------------

................................................................................................
YA

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................................................................................................
------------------------------------------------------------------------------................................................................................................
----------------------------------------------------------------------

Akta Nikah Nomor /Tanggal

I.
Telah dilangsungkan akad nikah
pada hari, tanggal, bulan, tahun (hijriyah /
masehi) dan pukul
II.

III.

SUAMI
1. Nama lengkap dan alias
2. Tempat dan tanggal lahir
3. Warga negara
4. Agama
5. Pekerjaan
6. Tempat tinggal
7. Pendidikan terakhir
8. Status sebelum menikah
9. Orang tua kandung
ISTRI
1. Nama lengkap dan alias
2. Tempat dan tanggal lahir
3. Warga negara
4. Agama
5. Pekerjaan
6. Tempat tinggal
7. Pendidikan terakhir
8. Status sebelum menikah
9. Orang tua kandung

IV. WALI NIKAH

1. Status wali (nasab/hakim)
2. Hubungan wali / sebab
3. Nama lengkap dan alias
4. Bin
5. Tempat dan tanggal lahir
6. Warga negara
7. Agama
8. Pekerjaan
9. Tempat tinggal
V.

MASKAWIN
1. Berupa dan berapa
2. Pembayaran (tunai/hutang)

VI. PERJANJIAN PERKAWINAN

Jika ada perjanjian sebutkan
V.

TAKLIK TALAK
Sesudah akad nikah suami membaca dan
menandatangani taklik talak (ya/tidak)

VI. Jika Pencatatan Nikah Berdasarkan

putusan pengadilan, sebutkan :
3. Pengadilan yang memutuskan
4. Nomor dan tanggal keputusan

Ketapang, .......................................
19 Februari 2013
Dikutip sebagai Duplikat sesuai dengan Akta Nikahnya
Yang mengutip Pegawai Pencatat Nikah
KUA ..................................................
KECAMATAN DELTA PAWAN

.....................................................
H. M. SYAFIIE, S.AG
NIP. ........................................
197505202000031001