(N.L.C. 34A-Pin.

2/85)

Kanun Tanah Negara

Borang 16 N
(Seksyen 278)

MELEPASKAN GADAIAN

(Setem hendaklah dilekatkan-atau pembayaran cukai diperakui-dalam ruang ini)

UNTUK KEGUNAAN PEJABAT PENDAITARAN

Ingatan pendaftaran dibuat dalam Dokumen/Dokumen Fail mengenai-

dokumen Hakmilik Daftar yang dijadualkan di bawah ini mulai
dari pukul.................pada.......haribulan..................................., Jilid .........................,.. ..........
19......... Folio ....................................
Pendaftar/PentadbirTanah .................................... Perserahan No:
T.M.
Negeri/Daerah ....................................................

Saya, .............................................................................................................................._.. .

········································································"••·····································································
·············..··································································································································
..................................................................................................................................................
.............. . ..................................................................................................................................
..
················································································································································
beralamat di ...............................................................................................................................

················································································································································
pemegang gadaian dalam gadaian yang diperihalkan dalam Jadual di bawah ini bagi *tanahfl:iahagian yang tak
dipecahkan atas tanah/pajakan/pajakan kecil yang diperihalkan sedemikian,

Dengan ini melepaskan daripada segala tanggungan yang selanjutnya di bawah gadaian ini mengenai

*kesemua *tanah/bahagian yang tak dipecahkan atas tanah/pajakan/pajakan kecil.

*mana-mana tanah/bahagian yang tak dipecahkan atas tanah/pajakan-pajakan kecil yang bertanda
"Dilepaskan" dalam ruangan 6 dalam Jadual itu.

.............................. . ...························,·············
Tandatangan (atau Lain-lain cara penyempurnaan).
oleh atau bagi pihak pemegang gadaian
 2

Di sini masukkan
nama pcnuhdan
Saya, ....................................................................................................................
lr.elayalan ,•rang
yangmenyaksikan.

dengan ini mengaku bahawa "'tandatangan/cap ibujari yang di atas itu telah "'ditulis/

dicapkan di hadapan saya pada..........haribulan..................., 19......., danadalah *tandatangan/

cap ibujari yang benar bagi-

Disinimas.ukkan
namaorang yang
menyempurna
k.an.

·········································..............................................................................................
..................................................................................................................................
.......................................... . ... .. . . . . . . . .......... . ............. . .. . . . ...........................................
'

·······································"'''''''''"''"······································..·····································
....................................................................................................................................
...................................................................................................................................
....................................................................................................................................
yang telah mengaku kepada saya-

(i) bahawa dia adalah cukup umur;

*(ii) bahawa dia adalah warganegara Malaysia;
(iii) bahawa dia telah menyempurnakan suratcara ini dengan kerelaan hatinya sendiri; dan
(iv) bahawa dia faham akan kandungan serta natijahnya.

Disaksikan dengan tandatangan saya pada........haribulan.................., 19.......

T
a
n
d
a
t
a
n
g
a
n
 3

JADUAL TANAH *DAN KEPENTINGAN

No. Berdaftar
•Bandar/ No. •Lot/ Jenis dan No. *pajakan/ No. Berdaftar Catatan
Pekanl Petak/P.T. Hakmilik pajakan kecil gadaian melepaskan
Mukim (jika ada) (Jika ada) (jika sesuai)

(I) (2) (3) (4) (5) (6)

• Potong sebagaimana yang sesuai.

[Borang ini diterjemahkan oleh Peguam Negara. Malaysia, menurut Pemberitahu Undangan No. 12 tahun 1964--A.G. 3309 S.F. I·
P.T. TM. 5/65 (4).j

L-J.P.N.. K.L.