SURAT KETERANGAN WALI

Yang bertanda tangan dibawah ini :

1. Nama......................................Umur..........Pekerjaan..................................................................
.Alamat.........................................................................................................................................
.
2. Nama......................................Umur..........Pekerjaan..................................................................
.Alamat.........................................................................................................................................
.
Menerangkan Bahwa :
Nama...............................................bin.............................................................................................
.Tempat tanggal lahir...............................................Agama
Islam,Pekerjaan......................................
Alamat................................................................................................................................................
Adalah betul hak Walinya Perempuan :
Nama :............................................binti....................................................umur......................Tahun
Agama Islam,Pekerjaan......................................................................................................................
Alamat................................................................................................................................................
Sebagai wali mujbir/Aqrob/Ab’’ad*)hubungan sebagai....................................................................
Demikian Keterangan ini dibuat dengan sebenarnya dan berani diangkat sumpah.
Sindangangin,......................20...
Tandatangan Wali Tandatangan kami berdua diatas

1. ..........................................
(.............................................
) 2. ..........................................
Menetahui, Mengetahui,
Kepala Desa Sindangangin P3UK/Desa Sindangangin

(MIS’SN SURATMAN ) (MUHTASUN)