Lampiran 26 KMA No.

296
Pasal 39 ayat (1)
Model : DN
DUPLIKAT KUTIPAN AKTA NIKAH

Akta Nikah Nomor

I. Telah dilangsungkan akad nikah :..............................................................................................................................
Pada hari / tanggal / bulan :..............................................................................................................................
Tahun (hijri dan masehi) :..............................................................................................................................

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 menikah :..............................................................................................................................
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 (Nasab / Hakim) :..............................................................................................................................
2. Hubungan Wali / sebab :..............................................................................................................................
3. Nama lengkap dan alias :..............................................................................................................................
4. Bin :..............................................................................................................................
5. Tempat tanggal lahir :..............................................................................................................................
6. Warga Negara :..............................................................................................................................
7. Agama :..............................................................................................................................
8. Pekerjaan :..............................................................................................................................
9. Tempat tinggal :..............................................................................................................................

V. MAS KAWIN
1. Berupa dan berapa :..............................................................................................................................
2. Pembayaran (Tunai/utang) :..............................................................................................................................

VI. PERJANJIAN PERKAWINAN

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

VII. TAKLIK TALAK

Sesudah akad nikah, suami membaca dan
menanda tangani taklik talak (ya/tidak) :..............................................................................................................................
VIII. Jika pencatatan nikah berdasarkan
Putusan pengadilan sebutkan
1. Pengadilan yang memtuskan :..............................................................................................................................
2. Nomor dan tanggal :..............................................................................................................................

Makassar,......................................................................
Dikutip sebagai duplikat sesuai dengan akta nikahnya
yang mengutip Pegawai Pencatatan Nikah
Kecamatan Wajo

H.HASAN SAKARING
NIP. 150 007 194