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Lampiran V

Keputusan Dirjen Bimas Islam No. 473 Tahun 2020

FORMULIR PEMERIKSAAN NIKAH


Model N8

BERITA ACARA PEMERIKSAAN NIKAH


Nomor :................./11.09.01.01/............./....................

Pada hari ini ................................... tanggal ................................................bulan ...................................................


tahun ................................................................bertempat di KUA kecamatan/KBRI/KJRI .......................................
kabupaten / kota ........................................ provinsi ................................................. telah dilakukan pemeriksaan
nikah terhadap :
1. Nama calon suami : ................................................................................................................
2. Nama calon istri : ................................................................................................................
3. Nama Wali : ................................................................................................................
4. Rencana akad perkawinan :
a. Hari/tanggal : ............................................................................................................ M
............................................................................................................. H
b. Waktu : ...............................................................................................................
c. Tempat akad perkawinan : ...............................................................................................................
...............................................................................................................
5. Nama Petugas Pemeriksa : ...............................................................................................................
NIP : ................................................................................................................
Jabatan : ...............................................................................................................

................................,.......................................20
Petugas

......................................................................

Catatan :
Nomor urut pendaftaran/nomor propinsi.nomor kabupaten/kota.nomor kecamatan.nomor
kelurahan/desa/bulan/tahun.

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