SURAT PERNYATAAN

Saya yang bertanda tangan di bawah ini:

Nama : ..............................................................................................................................
Tempat/Tgl Lahir : ..............................................................................................................................
Bangsa/ Agama : ..............................................................................................................................
Pekerjaan : ..............................................................................................................................
Alamat : ..............................................................................................................................
Status : Kawin/ Belum Kawin/ Duda/Janda

Anak kandung dari Suami Istri :

AYAH
Nama : ..............................................................................................................................
Tempat/Tgl Lahir : ..............................................................................................................................
Bangsa/ Agama : ..............................................................................................................................
Pekerjaan : ..............................................................................................................................
Alamat : ..............................................................................................................................

IBU
Nama : ..............................................................................................................................
Tempat/Tgl Lahir : ..............................................................................................................................
Bangsa/ Agama : ..............................................................................................................................
Pekerjaan : ..............................................................................................................................
Alamat : ..............................................................................................................................

Yang akan melangsungkan pernikahan dengan :

Nama : ..............................................................................................................................
Tempat/Tgl Lahir : ..............................................................................................................................
Bangsa/ Agama : ..............................................................................................................................
Pekerjaan : ..............................................................................................................................
Alamat : ..............................................................................................................................
Status : Kawin/ Belum Kawin/ Duda/Janda

Pernikahan tersebut akan dilaksanakan di RT ................................ Pada hari ..............................................

Tanggal ...............................................

Demikianlah Surat Pernyataan ini saya buat dengan sebenarnya dan berani menanggung semua akibat
hukum yang timbul di kemudian hari tanpa melibatkan pihak manapun.

Mengetahui Palembang, 2020

Orang Tua/ Wali Saya yang menyatakan

MENGETAHUI

Ketua Rukun Tetangga (RT)