BERITA ACARA

PELAYANAN KONSULTASI NIKAH DAN RUJUK

Pada Hari Tanggal Bulan Tahun Bertempat

Di Kua Kecamatan Lubuk Basung Kabupaten Agam Provinsi Sumatera Barat Telah Dilakukan
Konsultasi Layanan Nikah Dan Rujuk Terhadap

NAMA : _____________________________
NIK : _____________________________
TEMPAT/ TANGGAL LAHIR : _____________________________
PEKERJAAN : _____________________________
ALAMAT : _____________________________
ADAPUN PERMASALAHAN YANG DIKONSULTASIKAN YAITU :

PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

KESIMPULAN : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PEMOHON PENGHULU

____________ MASADI HARYONO, S.HI

198712022011011004
 BERITA ACARA
PELAYANAN KONSULTASI KEPENGHULUAN

Pada Hari Tanggal Bulan Tahun Bertempat

Di Kua Kecamatan Lubuk Basung Kabupaten Agam Provinsi Sumatera Barat Telah Dilakukan
Konsultasi Kepenghuluan Terhadap

NAMA : _____________________________
NIK : _____________________________
TEMPAT/ TANGGAL LAHIR : _____________________________
PEKERJAAN : _____________________________
ALAMAT : _____________________________
ADAPUN PERMASALAHAN YANG DIKONSULTASIKAN YAITU :

PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

KESIMPULAN : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PEMOHON PENGHULU

____________ MASADI HARYONO, S.HI

198712022011011004
 BERITA ACARA
PELAYANAN KONSULTASI RUMAH TANGGA

Pada Hari Tanggal Bulan Tahun Bertempat

Di Kua Kecamatan Lubuk Basung Kabupaten Agam Provinsi Sumatera Barat Telah Dilakukan
Konsultasi Rumah Tangga Terhadap

NAMA : _____________________________
NIK : _____________________________
TEMPAT/ TANGGAL LAHIR : _____________________________
PEKERJAAN : _____________________________
ALAMAT : _____________________________
ADAPUN PERMASALAHAN YANG DIKONSULTASIKAN YAITU :

PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

KESIMPULAN : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PEMOHON PENGHULU

____________ MASADI HARYONO, S.HI

198712022011011004
 BERITA ACARA
PELAYANAN KONSULTASI HUKUM ISLAM

Pada Hari Tanggal Bulan Tahun Bertempat

Di Kua Kecamatan Lubuk Basung Kabupaten Agam Provinsi Sumatera Barat Telah Dilakukan
Konsultasi Layanan Hukum Islam Terhadap

NAMA : _____________________________
NIK : _____________________________
TEMPAT/ TANGGAL LAHIR : _____________________________
PEKERJAAN : _____________________________
ALAMAT : _____________________________
ADAPUN PERMASALAHAN YANG DIKONSULTASIKAN YAITU :

PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PEMOHON : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PENGHULU : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

KESIMPULAN : ________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

PEMOHON PENGHULU

____________ MASADI HARYONO, S.HI

198712022011011004