F-2.

01
Provinsi : Jawa Tengah
Kabupaten : Sragen
Kecamatan : _____________________________________________
Desa / Kelurahan : _____________________________________________

FORMULIR PELAPORAN PENCATATAN SIPIL

PERCERAIAN

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 PERCERAIAN
1. No. Akta Perkawinan : _______________________________________________________
2. Tgl Akta Perkawinan : _______________________________________________________
3. Tempat Pencatatan Perkawinan : _______________________________________________________
4. Nama Pengadilan : _______________________________________________________
5. Tgl Putusan Pengadilan : _______________________________________________________
6. No. Putusan Pengadilan : _______________________________________________________
7. No. Surat Keterangan Panitera : _______________________________________________________
Pengadilan
8. Tgl Surat Keterangan Panitera : _______________________________________________________
Pengadilan
9. Tgl Melapor : _______________________________________________________

Sragen, _____ __________________ 2020

Pelapor,
( _______________________________________ )