PEMERINTAH PROVINSI DAERAH KHUSUS IBUKOTA JAKARTA

DINAS KEPENDUDUKAN DAN PENCATATAN SIPIL

SUKU DINAS KEPENDUDUKAN DAN PENCATATAN SIPIL
KOTA ADMINISTRASI JAKARTA TIMUR
Jl. Cipinang Baru Raya No. 16 Pulo Gadung, Jakarta Timur
Telp. ( 021 ) 489 57 25, 470 15 52, 478 646 72 Fax. (021) 478 646 72
JAKARTA
Kode Pos : 13240

FORMULIR PERMOHONAN KIA

1. Nama Siswa : .........................................................................................................

2. Tempat, Tanggal Lahir : .........................................................................................................

3. Agama : .........................................................................................................
4. Jenis Kelamin : .........................................................................................................
5. NIK : .........................................................................................................
6. No. Akta Kelahiran : .........................................................................................................
7. Nama Orang Tua
- Nama Ayah : .........................................................................................................
- Nama Ibu : .........................................................................................................
8. No. Buku Nikah/Akta Kawin : .........................................................................................................
9. Alamat Rumah : .........................................................................................................
10. No. Telephone Orang Tua : .........................................................................................................

Jakarta, ...............................................
Orang Tua / Wali ................................

( ........................................................ )

Dilengkapi dengan :
1. Foto Copy Akta Kelahiran
2. Foto Copy KK dan KTP-el Orang Tua/Wali
3. Foto Copy Buku Nikah/ Akta Perkawinan
4. Pas Foto siswa berwarna 4x6 (1 lembar)