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. 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 : Ayah :............................................................................................................................ ..
: Ibu :............................................................................................................................ ..

III. 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 :............................................................................................................................ ..

IV. 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 :............................................................................................................................ ..

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

VI. PERJANJIAN PERKAWINAN

Jika ada sebutkan :............................................................................................................................ ..

VII. TAKLIK TALAK

Sesudah akad nikah, suami membaca dan
menanda tangani taklik talak (ya/tidak) :..............................................................................................................................
VIII. 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