BENTUK W.

IKRAR WAKAF
BISMILLAHIRRAHMANIRRAHIM

Yang Bertanda tanagaan di bawah ini saya

Nama lengkap : ...........................................................................................................................................
Tempat dan Tanggal Lahir/umur : ...........................................................................................................................................
Agama : ...........................................................................................................................................
Pekerjaan : ...........................................................................................................................................
Jabatan (bagi Wakif Badan Hukum) : ...........................................................................................................................................
Kewarganegaraan : ...........................................................................................................................................
Tempat tinggal : ...........................................................................................................................................
: ...........................................................................................................................................
Bertindak untuk dan atas nama : ...........................................................................................................................................
Pada hari ini : ...........................................................................................................................................
Tanggal : ...........................................................................................................................................
Dengan ini mewakafkan sebidang tanah hak milik saya :
Berupa 1) : ...........................................................................................................................................
Sertifikat/Persil 2) nomor : ...........................................................................................................................................
Kelas Desa : ...........................................................................................................................................
Ukuran Panjang : ...........................................................................................................................................
Lebar : ...........................................................................................................................................
Luas : ...........................................................................................................................................
Terletak di : ...........................................................................................................................................
Desa : ...........................................................................................................................................
Kecamatan : ...........................................................................................................................................
Kabupaten/Kota 2) : ...........................................................................................................................................
Provinsi : ...........................................................................................................................................
dengan batas-batas :
Sebelah timur : ...........................................................................................................................................
barat : ...........................................................................................................................................
utara : ...........................................................................................................................................
selatan : ...........................................................................................................................................
Untuk keperluan 3) : ...........................................................................................................................................
Wakaf tanah tersebut diurus oleh Nazhir yang diwakili oleh :
Nama lengkap : ...........................................................................................................................................
Tempat dan Tanggal Lahir/umur : ...........................................................................................................................................
Agama : ...........................................................................................................................................
Pekerjaan : ...........................................................................................................................................
Jabatan (bagi Wakif Badan Hukum) : ...........................................................................................................................................
Kewarganegaraan : ...........................................................................................................................................
Tempat tinggal : ...........................................................................................................................................
: ...........................................................................................................................................

Ikrar Wakif ini diucapkan / dibacakan 2) di hadapan PPAIW kecamatan .......................................................................................................

............................................................... Kabupaten/Kota 2) ..........................................................................................................................
Propinsi ........................................................................................
Dengan disaksikan oleh saksi-saksi :
1.. Nama lengkap : ...........................................................................................................................................
Tempat dan Tanggal Lahir/umur : ...........................................................................................................................................
Agama : ...........................................................................................................................................
Pekerjaan : ...........................................................................................................................................
Jabatan (bagi Wakif Badan Hukum) : ...........................................................................................................................................
Kewarganegaraan : ...........................................................................................................................................
Tempat tinggal : ...........................................................................................................................................

2. Nama lengkap : ...........................................................................................................................................

Tempat dan Tanggal Lahir/umur : ...........................................................................................................................................
Agama : ...........................................................................................................................................
Pekerjaan : ...........................................................................................................................................
Jabatan (bagi Wakif Badan Hukum) : ...........................................................................................................................................
Kewarganegaraan : ...........................................................................................................................................
Tempat tinggal : ...........................................................................................................................................

Ikrar Wakaf dibuat dalam rangkap tiga :

Lembar pertama untuk Nadzir
Lembar kedua untuk PPAIW
lembar ketiga untuk Wakif
Demikian ikrar wakaf ini saya buat atas kehendak sendiri dan tanpa paksaan pihak lain. :

....................................................................................

Nazhir Wakif

Meterai 6.000,-

(...................................................................) (...................................................................)

Saksi-saksi :
Mengetahui
1. ............................................. (........................................) Kepala kantor Agama Kecamatan/
Pejabat Pembuat Akta Ikrar Wakaf
2. ............................................. (.........................................)
Meterai 6.000,-

(...................................................................)
NIP. ............................................................

Keterangan :
1) Diisi salah satu dari sawah, pekarangan, kebun, atau tambak.
2) Coret yang tidak perlu.
3) Diisi salah satu dari tujuan wakaf.
a. Pembangunan tempat peribadatan, termasuk di dalamnya masjid, langgar dan musholla.
b. Keperluan umum, termasuk di dalamnya bidang pendidikan dari tingkat kanak-kanak, tingkat dasar sampai tingkat tinggi serta
tempat penyantunan anak yatim piatu, tuna netra, tuna wisma, atau keperluan umum lainnya sesuai dengan ajaran Islam.