SURAT PERNYATAAN NIKAH KAWIN

No Urut :
Yang bertanda tangan di bawah ini :
Pada hari
1. Calon Nama :.....................................................................................................
Suami Tgl lahir :.....................................................................................................
Warganegara :.....................................................................................................
Agama : ....................................................................................................
Pekerjaan :.....................................................................................................
Alamat :.....................................................................................................
2. Calon Nama :.....................................................................................................
Istri Tgl Lahir :.....................................................................................................
Warganegara :.....................................................................................................
Agama :.....................................................................................................
Pekerjaan :.....................................................................................................

3. Status Wali Bapak/Ibu :.....................................................................................................

Nama : ....................................................................................................
Tgl Lahir :.....................................................................................................
Warganegara :.....................................................................................................
Agama :.....................................................................................................
Pekerjaan :.....................................................................................................
Alamat :.....................................................................................................

Mas kawin berupa :...........................................................................................

DENGAN INI SAYA MENYATAKAN BAHWA DENGAN KEDUA NAMA CALON
SUAMI ISTRI DI ATAS BENAR-BENAR TELAH MENIKAH DENGAN
DI UCAPKANNYA TA’LIK TALAK DI HADAPAN PARA SAKSI
PERNIKAHAN INI TELAH SESUAI DENGAN SYARIAT ISLAM DAN
BELUM TERCATAT DI KUA MANAPUN

Kepada pihak yang berkepentingan/berwajib akan menjadi maklumadanya

Saksi – saksi :
1. Nama :
Alamat :
2. Nama :
Alamat :

Pengnatin Laki-laki Pengantin Wanita Wali Saksi-saksi

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