F-2.

01 PERMENDAGRI 109 TAHUN 2019

Provinsi : SULAWESI SELATAN
Kabupaten/Kota : MAKASSAR
Kecamatan : .................................................................................................................
Desa/Kelurahan : .................................................................................................................
Kode Wilayah : 7371……………….
FORMULIR PELAPORAN PENCATATAN SIPIL DI DALAM WILAYAH NKRI
PERUBAHAN NAMA

Data Pelapor
1. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
2. Nama Lengkap : ...................................................................................................................................................................................
3. Tempat, Tanggal Lahir : ...................................................................................................................................................................................
4. Pekerjaan : ...................................................................................................................................................................................
5. Nomor Telp. / HP : ...................................................................................................................................................................................
6. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………

Data Perubahan Nama

1. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
2. Nama Anak : ...................................................................................................................................................................................
3. Perubahan menjadi : ...................................................................................................................................................................................
4. Alasan Perubahan : ...................................................................................................................................................................................
...................................................................................................................................................................................
5. Nomor Akta Kelahiran : ...................................................................................................................................................................................
6. Nama Ayah/Ibu/Wali : ...................................................................................................................................................................................
(Bagi yang di Bawah Umur)
7. NIK Nama Ayah/Ibu/Wali : ...................................................................................................................................................................................
8. Kewarganegaraan : ...................................................................................................................................................................................
9. Nomor Penetapan Pengadilan : ...................................................................................................................................................................................
10. Tanggal Penetapan Pengadilan : ...................................................................................................................................................................................
11. Nama Lembaga Pengadilan : ...................................................................................................................................................................................
12. Nomor Telp. / HP / WA (*) : ...................................................................................................................................................................................
13. Email Yang Masih Aktif (*) : ...................................................................................................................................................................................
Makassar,……………………………………………20……

Mengetahui : Pelapor
Pejabat Dukcapil Yang Membidangi

…………………………………………………. ………………………………………………….

Nb. Tanda (*) Wajib Isi