BERITA ACARA PEMBAYARAN HUTANG

Pada hari ini hari .......................................... tanggal ........................................ bulan ..........................................

tahun ..............................................................................., yang bertanda tangan di bawah ini :
1.

Nama

: ......................................................................................................................................................

2.

Nama

: ......................................................................................................................................................

1.
2.
3.
4.

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Tempat/Tgl. Lahir
Jenis Kelamin :
Agama
:
Pekerjaan
:
Alamat
:

: ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Dalam hal ini bertindak untuk dan atas nama .......................................................................................................,
yang untuk selanjutnya disebut PIHAK PERTAMA
Tempat/Tgl. Lahir
Jenis Kelamin :
Agama
:
Pekerjaan
:
Alamat
:

: ......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
Dalam hal ini bertindak untuk dan atas nama .......................................................................................................,
yang untuk selanjutnya disebut PIHAK KEDUA
Dihadapan Allah SWT/Tuhan YME dan Para Saksi, telah dilakukan pembayaran Hutang atas
nama :
Nama
: ......................................................................................................................................................
Tempat/Tgl. Lahir : ......................................................................................................................................................
Jenis Kelamin
: ......................................................................................................................................................
Agama
: ......................................................................................................................................................
Pekerjaan
: ......................................................................................................................................................
Alamat
: ......................................................................................................................................................
......................................................................................................................................................
Yang menggunakan jaminan berupa : ..................................................................................................................................
dan perjanjian .................................................................................................................................................................................
Pembayaran dilakukan oleh PIHAK PERTAMA yang terkait sebagai Ahli Waris atas jaminan
tersebut kepada PIHAK KEDUA secara tunai sejumlah : Rp. ....................................................................................
(............................................................................................................................................................................................................)
yang merupakan jumlah total hutang atas perincian :

Demikian berita acara ini dibuat dengan sebenarnya, dalam kondisi Para Pihak sehat
jasmani dan rohani serta tidak dalam tekanan pihak manapun, ditandatangani dihadapan Para Saksi
diatas materai cukup di ....................................................................................... pada hari .................................................
tanggal .......................................... bulan .......................................... tahun ...............................................................................
PIHAK PERTAMA,

PARA PIHAK

..................................................................
Saksi I,

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

PIHAK KEDUA,

..................................................................
Para Saksi

Saksi II,

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