KM No.

177 Tahun 2007

DUPLIKAT KUTIPAN AKTA NIKAH Pasal 39 Ayat 1
Model DM
Nomor : Kk.21.19.1 / Pw. 00/69 / I / 2017

I. Akta Nikah Nomor /Tanggal : ................................................................................................

Telah dilangsungkan akad nikah : ................................................................................................
Pada hari, tanggal, bulan,
tahun (hijriyah / Masehi)
Dan pukul : ................................................................................................

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 nikah : ................................................................................................
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 : ................................................................................................
2. Hubungan Wali / Sebab : ................................................................................................
3. Nama lengkap dan alias : ................................................................................................
4. Tempat dan tanggal lahir : ................................................................................................
5. Warga negara : ................................................................................................
6. Agama : ................................................................................................
7. Pekerjaan : ................................................................................................
8. Tempat tinggal : ................................................................................................

V. MASKAWIN
1. Berupa apa dan berapa : ................................................................................................
2. Pembayaran (tunai/utang) : ................................................................................................

VI. PERJANJIAN PERKAWINAN

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

V. TAKLIK TALAK
Sesudah akad nikah suami membaca
dan menandatangani taklik talak (ya/tidak) : ................................................................................................

VI. Jika Pencatatan Nikah Berdasarkan

putusan pengadilan, sebutkan :
1. Pengadilan yang memutuskan : ................................................................................................
2. Nomor dan tanggal keputusan : ................................................................................................

Ketapang, .......................................

Dikutip sebagai Duplikat sesuai dengan Akta Nikahnya

Yang mengutip Pegawai Pencatat Nikah
KUA ..................................................

.....................................................
NIP. ........................................