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Lampiran 26 PMA No.

2 Tahun 1990
Pasal 31 Ayat (1)
Model DN
DUPLIKAT KUTIPAN AKTA NIKAH
Kk.14.04.12/PW.01/521/2013
Nomor : ....................................................
500/04 /III/1996 Tanggal : 04 MARET 1996
Akta Nikah Nomor /Tanggal : ................................................................................................
JUM’AT
I. Telah dilangsungkan akad nikah : ................................................................................................
16 FEBRUARI 1996
pada hari, tanggal, bulan, tahun (hijriyah / : ................................................................................................
21.00
masehi) dan pukul : ................................................................................................

II. SUAMI
ERWANDI ----------------------------------------------------------------
1. Nama lengkap dan alias : ................................................................................................
KETAPANG, 21 TAHUN
2. Tempat dan tanggal lahir : ................................................................................................
INDONESIA
3. Warga negara : ................................................................................................
ISLAM
4. Agama : ................................................................................................
SWASTA
5. Pekerjaan : ................................................................................................
DESA SUNGAI AWAN KANAN
6. Tempat tinggal : ................................................................................................
------------------------------------------------------------------------------
7. Pendidikan terakhir : ................................................................................................
JEJAKA
8. Status sebelum menikah : ................................................................................................
SAIPULLAH
9. Orang tua kandung Ayah : ................................................................................................
MARIATON
Ibu : ................................................................................................
III. ISTRI
RUMILAH-----------------------------------------------------------------
1. Nama lengkap dan alias : ................................................................................................
KETAPANG,TAHUN 1975
2. Tempat dan tanggal lahir : ................................................................................................
INDONESIA
3. Warga negara : ................................................................................................
ISLAM
4. Agama : ................................................................................................
SWASTA
5. Pekerjaan : ................................................................................................
DESA SUNGAI AWAN KIRI
6. Tempat tinggal : ................................................................................................
------------------------------------------------------------------------------
7. Pendidikan terakhir : ................................................................................................
PERAWAN
8. Status sebelum menikah : ................................................................................................
MUHAMMAD ARBI
9. Orang tua kandung Ayah : .……………………………………………………………………
HASIDAH
Ibu : ................................................................................................
IV. WALI NIKAH
NASAB
1. Status wali (nasab/hakim) : ................................................................................................
AYAH KANDUNG
2. Hubungan wali / sebab : ................................................................................................
MUHAMMAD ARBI
3. Nama lengkap dan alias : ................................................................................................
------------------------------------------------------------------------------
4. Bin : ................................................................................................
KETAPANG, TAHUN 1949
5. Tempat dan tanggal lahir : ................................................................................................
INDONESIA
6. Warga negara : ................................................................................................
ISLAM
7. Agama : ................................................................................................
TANI
8. Pekerjaan : ................................................................................................
DESA SUNGAI AWAN KIRI
9. Tempat tinggal : ................................................................................................

V. MASKAWIN
SEBENTUK CINCIN EMAS
1. Berupa dan berapa : ................................................................................................
TUNAI
2. Pembayaran (tunai/hutang) : ................................................................................................

VI. PERJANJIAN PERKAWINAN


-------------------------------------------------------------------------------
Jika ada perjanjian sebutkan : ................................................................................................

V. TAKLIK TALAK
YA
Sesudah akad nikah suami membaca dan : ................................................................................................
menandatangani taklik talak (ya/tidak)

VI. Jika Pencatatan Nikah Berdasarkan


putusan pengadilan, sebutkan :
-------------------------------------------------------------------------------
1. Pengadilan yang memutuskan : ................................................................................................
-------------------------------------------------------------------------------
2. Nomor dan tanggal keputusan : ................................................................................................
29 Oktober 2013
Ketapang, .......................................

Dikutip sebagai Duplikat sesuai dengan Akta Nikahnya


Yang mengutip Pegawai Pencatat Nikah
KECAMATAN DELTA PAWAN
KUA ..................................................

H. M. SYAFI’IE, S.AG
.....................................................
197505202000031001
NIP. ........................................
Lampiran 26 PMA No. 2 Tahun 1990
Pasal 31 Ayat (1)
Model DN
DUPLIKAT KUTIPAN AKTA NIKAH
Kk.14.04.12/PW.01/73/2013
Nomor : ....................................................
116 Tanggal : Oktober 1970
Akta Nikah Nomor /Tanggal : ................................................................................................
I. Telah dilangsungkan akad nikah : ................................................................................................
Oktober 1970 M
pada hari, tanggal, bulan, tahun (hijriyah / : ................................................................................................
masehi) dan pukul : ................................................................................................

II. SUAMI
ZAMHURI ---------------------------------------------------------------
1. Nama lengkap dan alias : ................................................................................................
KALINILAM, 25 TAHUN
2. Tempat dan tanggal lahir : ................................................................................................
INDONESIA
3. Warga negara : ................................................................................................
ISLAM
4. Agama : ................................................................................................
TANI
5. Pekerjaan : ................................................................................................
KALINILAM
6. Tempat tinggal : ................................................................................................
7. Pendidikan terakhir : ................................................................................................
JEJAKA
8. Status sebelum menikah : ................................................................................................
MUHAMAD
9. Orang tua kandung Ayah : ................................................................................................
AYU RABAYA
Ibu : ................................................................................................
III. ISTRI
MASTINA
1. Nama lengkap dan alias : ................................................................................................
----------------------------------------------------------------KP.TENGAH,
2. Tempat dan tanggal lahir : ................................................................................................
19 TAHUN
3. Warga negara : ................................................................................................
INDONESIA
4. Agama : ................................................................................................
ISLAM
5. Pekerjaan : ................................................................................................
TANI
6. Tempat tinggal : ................................................................................................
KP.SAMPIT
7. Pendidikan terakhir : ................................................................................................
8. Status sebelum menikah : ................................................................................................
PERAWAN
9. Orang tua kandung Ayah : .……………………………………………………………………
UTI AMRI
Ibu : ................................................................................................
JAINIAH
IV. WALI NIKAH
1. Status wali (nasab/hakim) : ................................................................................................
HAKIM
2. Hubungan wali / sebab : ................................................................................................
3. Nama lengkap dan alias : ................................................................................................
H.HASAN ZULKIFLI
4. Bin : ................................................................................................
5. Tempat dan tanggal lahir : ................................................................................................
6. Warga negara : ................................................................................................
7. Agama : ................................................................................................
8. Pekerjaan : ................................................................................................
9. Tempat tinggal : ................................................................................................

V. MASKAWIN
1. Berupa dan berapa : ................................................................................................
RP.25
2. Pembayaran (tunai/hutang) : ................................................................................................
TUNAI
VI. PERJANJIAN PERKAWINAN
Jika ada perjanjian sebutkan : ................................................................................................
-------------------------------------------------------------------------------
V. TAKLIK TALAK
Sesudah akad nikah suami membaca dan : ................................................................................................
YA
menandatangani taklik talak (ya/tidak)

VI. Jika Pencatatan Nikah Berdasarkan


putusan pengadilan, sebutkan :
3. Pengadilan yang memutuskan : ................................................................................................
-------------------------------------------------------------------------------
4. Nomor dan tanggal keputusan : ................................................................................................
----------------------------------------------------------------------
Ketapang, .......................................
19 Februari 2013
Dikutip sebagai Duplikat sesuai dengan Akta Nikahnya
Yang mengutip Pegawai Pencatat Nikah
KUA ..................................................
KECAMATAN DELTA PAWAN

.....................................................
H. M. SYAFI’IE, S.AG
NIP. ........................................
197505202000031001

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