Kode : F – 2.

01
Kabupaten : Lampung Barat
Kecamatan :
Desa/Kelurahan : Kode Wilayah :

FORMULIR PELAPORAN KELAHIRAN

Yang Bertanda tangan di bawah ini :

(NAMA YANG MELAPORKAN)
Nama Lengkap : ........................................................................................................................................
NIK : ........................................................................................................................................
Umur : ........................................................................................................................................
Pekerjaan : ........................................................................................................................................
Alamat : ...........................................................................................RT / RW..............................
Hubungan dengan si bayi : ........................................................................................................................................
Melaporkan bahwa telah lahir :
(NAMA YANG MEMBUAT AKTA)
Pada hari : ........................................................................................................................................
Tanggal : ........................................................................................................................................
Pukul : ........................................................................................................................................
Jenis kelahiran : Tunggal / Kembar *)......................................................................................................
Nama **) : ........................................................................................................................................
Jenis Kelamin **) : ........................................................................................................................................
Anak ke : ........................................................................................................................................
NIK : ........................................................................................................................................

Dari Seorang Ibu :

(NAMA IBU)
Nama Lengkap : ........................................................................................................................................
NIK : ........................................................................................................................................
Tanggal Lahir / Umur : ........................................................................................................................................
Kewarganegaraan : ........................................................................................................................................
Pekerjaan : ........................................................................................................................................
Alamat : ...........................................................................................RT / RW..............................

Istri dari :
(NAMA BAPAK)
Nama Lengkap : ........................................................................................................................................
NIK : ........................................................................................................................................
Tanggal Lahir / Umur : ........................................................................................................................................
Kewarganegaraan : ........................................................................................................................................
Pekerjaan : ........................................................................................................................................
Alamat : ...........................................................................................RT / RW..............................
SAKSI I SAKSI II
Nama :................................................ Nama : RUSLI, BA
NIK :................................................ NIK : 1804040406630002
Umur :................................................ Umur : 49 TAHUN
Pekerjaan :................................................ Pekerjaan : PEGAWAI NEGERI SIPIL
Alamat :................................................ Alamat : WAY MENGAKU

Tanda Tangan Tanda Tangan

( .................................. ) ( R U S L I, BA )

Terlampir disertakan persyaratan-persyaratan sebagai berikut :

1.Surat Kelahiran dari penolong kelahiran (Asli)
2.Fotocopy Ijazah bagi yang sudah memiliki .............-.......................-20......
3.Fotocopy KTP dan Kartu Keluarga orang tua Pelapor
4.Fotocopy Buku Nikah / Akta Perkawinan orang tua
5. Melampirkan Penetapan Pengadilan Negeri bagi yg Berumur melebihi 1 Tahun
6.Stopmap Folio 2 buah

*) Coret yang tidak perlu (Nama :......................................)

**) Apabila jenis kelamin kembar tuliskan nama-nama
yang diberikan kepada bayi kembar secara berurutan
dari masing-masing bayi tersebut.