F-2.

01
Provinsi : _____________________________________________
Kabupaten : _____________________________________________
Kecamatan : _____________________________________________
Desa / Kelurahan : _____________________________________________

FORMULIR PELAPORAN PENCATATAN SIPIL

KELAHIRAN

DATA PELAPOR
1. Nama Lengkap : ___________________________________________________________________
2. NIK : ___________________________________________________________________
3. No. Dok. Perjalanan : ___________________________________________________________________
4. No. KK : ___________________________________________________________________
5. Kewarganegaraan : ___________________________________________________________________

SAKSI I
1. NIK : _________________________________________________________________
2. Nama lengkap : _________________________________________________________________
3. Tgl Lahir / umur : Tgl. Lahir _____________________________________ Umur ______________
4. Pekerjaan : _________________________________________________________________
5. Alamat : _________________________________________________________________

SAKSI II
1. NIK : _________________________________________________________________
2. Nama lengkap : _________________________________________________________________
3. Tgl Lahir / umur : Tgl. Lahir _____________________________________ Umur ______________
4. Pekerjaan : _________________________________________________________________
5. Alamat : _________________________________________________________________

DATA ORANG TUA

AYAH
1. Nama Lengkap : ___________________________________________________________________
2. NIK : ___________________________________________________________________
3. Tempat Lahir : ___________________________________________________________________
4. Tgl Lahir : ___________________________________________________________________
5. Kewarganegaraan : ___________________________________________________________________

IBU
1. Nama Lengkap : ___________________________________________________________________
2. NIK : ___________________________________________________________________
3. Tempat Lahir : ___________________________________________________________________
4. Tgl Lahir : ___________________________________________________________________
5. Kewarganegaraan : ___________________________________________________________________

DATA BAYI / ANAK

1. Nama Lengkap : ___________________________________________________________________
2. Jenis Kelamin : ___________________________________________________________________
3. Tempat dilahirkan : ___________________________________________________________________
4. Hari dan Tgl Lahir : Hari __________________________ Tgl lahir ______________________________
5. Pukul / Jam : ___________________________________________________________________
6. Jenis Kelahiran : a. Tunggal b. Kembar 2 c. Kembar 3 d. Kembar 4 e. Lainnya
7. Kelahiran ke : ___________________________________________________________________
8. Penolong Kelahiran : a. Dokter b. Bidan / Perawat c. Dukun d. Lainnya
9. Berat Bayi : ___________________________________________________________________
10. Panjang Bayi : ___________________________________________________________________

Sragen, _____ __________________ 2020

Pelapor,

( _______________________________ )