Formulir Permohonan Ganti Nama

Yth.
Kepala Kantor Pertanahan
Kota Administrasi Jakana Barat
di Jakarta

Dengan Hormat,
Yang bertanda tangan di bawah ini :
Nama : ..............................................................................................................................................................................
Tempat, tgl. lahir : ..............................................................................................................................................................................
NIK : …………………………………………………………………………. Umur : .................. tahun
Alamat : ..............................................................................................................................................................................
No. Telp/HP : ………………………………………… email : .........................................................................................

Dalam hal ini bertindak selaku kuasa dari :

...........................................................................................................................................................................................................................
dengan ini mengajukan permohonan Ganti Nama atas sebidang tanah hak :
Terletak di : ...............................................................................................................................................................................
Kelurahan : ...............................................................................................................................................................................
Kecamatan : ...............................................................................................................................................................................
Kota : Kota Administrasi Jakarta Barat
Nomor Hak : ...............................................................................................................................................................................

Untuk melengkapi permohonan dimaksud bersama ini kami lampirkan :

1. Sertipikat Hak Atas Tanah..............................................................................................................
2. Akta/Surat Keterangan Ganti Nama ...............................................................................................
3. Surat Keputusan/Penetapan Pengadilan .........................................................................................
4. Fotocopy KTP/KK Pemohon dan Kuasanya apabila dikuasakan ..................................................
5. Surat Kuasa Permohonan ...............................................................................................................
6. Surat Pengantar dari PPAT.............................................................................................................
7. Surat Tugas dari PPAT ...................................................................................................................
8. ........................................................................................................................................................
9. ........................................................................................................................................................
10. ........................................................................................................................................................

Hormat Kami,

…………………………………………

* Semua berkas yang menjadi lampiran permohonan ini adalah sah dan apabila dikemudian hari dapat dibuktikan itu palsu,
pemohon bersedia dituntut sesuai dengan ketentuan hukum yang berlaku.

Melayani, Profesional, Terpercaya