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Tl:N l'IVII:
111:C.UU. TAN 111:U..U.li
GAMPONGPALOHTEUNGOH
SllRAT KETERA.'IUAN REKOMENPASI
Nomor. 141 / l'T ,, ., I 2022

Yang bertanda tangan d, bawah ini Keuchik Gampong Paloh Tcungoh, Kecamatan Kcumala.
Kabupatcn P!d1e Provins! Aa:h, dengan rm ment:ranglran b.ihwa ·
Ism j
Nam., : ASMA UL HUSNA
NIK : I 107226606970002
Tempar/ Tgl.Lah1r : Paloh Teungoh/26 Jum 1997
Jeni, k:clamin : Pcrcmpuan
Pck:cnaan : Tam
AJamar Sd:arang : Gampoi\8 Paloh Teungoh Kea.matan Kcumala Kabupatcn P1d1c
Soa.ml ;
Nama · ANTONl
NIK : 1107092505980002
Tcmpat/ Tg!.Lahir : Sigl.J I 26 Mei IIJ98
Jenis kdamin . Laki-laki
Pckcrjaan : Tani
Alamat Sctarang · Gampong Paloh Tcungoh Keamat,m Keumala Kabupaten Pi die

Ikna.r yang namanya 1t.�bu1 di ata� adalah p.uangan suami LSTcri yani;i sah ;

Menunn seepcngcrahuan k:am1 kchidu-pan rumah tangga mereka sudah tldak hnmonis lagi,
nleh karena rtu plhak kam1 t\J.rut mcrekomendasikan agar perkara dan/atau pcr!eh,ihan
kcluarga. yang lilmaksud dap,u di.'lele5at\::an pad.a lantor �ahkamah Sya.r'1ydh S,gli,

Dem.lkian surar keterangan ini dill:cluarkan dengan sebcnamya unruk dapat d.J.pttgunakan
seperlunya

Palob Teungoh. 23 Mei 20�

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