Anda di halaman 1dari 1

Lampiran 26 KMA No.

296
Pasal 39 ayat (1)
Model : DN

DUPLIKAT KUTIPAN AKTA NIKAH


Akta Nikah Nomor
I.
Telah dilangsungkan akad nikah
Pada hari / tanggal / bulan
Tahun (hijri dan masehi)
II.

III.

IV.

V.

VI.

VII.

VIII.

SUAMI
1. Nama lengkap dan alias
2. Tempat dan tanggal lahir
3. Warga Negara
4. Agama
5. Pekerjaan
6. Tempat tinggal
7. Status sebelum menikah
8. 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. Status sebelum menikah
8. Orang Tua Kandung

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

: Ayah
: Ibu

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

: Ayah
: Ibu

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

WALI NIKAH
1. Status Wali (Nasab / Hakim)
2. Hubungan Wali / sebab
3. Nama lengkap dan alias
4. Bin
5. Tempat tanggal lahir
6. Warga Negara
7. Agama
8. Pekerjaan
9. Tempat tinggal

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

MAS KAWIN
1. Berupa dan berapa
2. Pembayaran (Tunai/utang)

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

PERJANJIAN PERKAWINAN
Jika ada sebutkan

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

TAKLIK TALAK
Sesudah akad nikah, suami membaca dan
menanda tangani taklik talak (ya/tidak) :..............................................................................................................................
Jika pencatatan nikah berdasarkan
Putusan pengadilan sebutkan
1. Pengadilan yang memtuskan
:..............................................................................................................................
2. Nomor dan tanggal
:............................................................................................................................ ..

Makassar,......................................................................
Dikutip sebagai duplikat sesuai dengan akta nikahnya
yang mengutip Pegawai Pencatatan Nikah
Kecamatan Wajo

H.HASAN SAKARING
NIP. 150 007 194