PEMERINTAH KABUPATEN REMBANG

DINAS KEPENDUDUKAN DAN PENCATATAN SIPIL

Jl. Pemuda KM. 2,5 Telp / Fax. 0295-691738
Rembang 59219

FORMULIR PERMOHONAN
KARTU IDENTITAS ANAK ( KIA )

No : ............ NIK Anak : ................................................

Nomor Akta Kelahiran : .................................................................................................................................

Nama Anak : .................................................................................................................................
Tempat Lahir : .................................................................................................................................
Tanggal lahir : .................................................................................................................................
Nama Ayah : .................................................................................................................................
Nama Ibu : .................................................................................................................................
Alamat Rumah : .................................................................................................................................
No. HP : .................................................................................................................................

Rembang, .............................. 2021

Orang Tua / Wali Pemohon

.............................................................
*Ditulis Nama Lengkap dan Ditandatangani

DIISI OLEH PETUGAS

No. Nama Berkas Ada Tidak Ada
1. Formulir Permohonan
2. Photo Copy Akta Kelahiran
3. Photo Copy Kartu Keluarga ( KK )
4. Photo Copy KTP-el Orang Tua/Wali
5. Pas Photo Berwarna Ukuran 4 X 6
6. Tanggal Koreksi
7. Paraf Petugas Koreksi