DOKUMEN

SERTIFIKAT TANAH LEMBAGA

TINGKAT ISTITUT
BP 933721 DAFTAR ISIAN 206

BADAN PERTAHANAN NASINAL

REPUBLIK INDONESIA

SERTIPIKAT
(TANDA BUKTI HAK)

BADAN PERTAHANAN NASIONAL

 REPUBLIK INDONESIA

SERTIPIKAT
HAK:......................................NO...............................

PROVINSI :.......................................................

KABUPATEN/KOTA :......................................................

KECAMATAN :.....................................................

DESA/KELURAHAN :....................................................

DAFTAR ISIAN 207

NO..............................

DAFTAR ISIAN 208

NO.............................

KANTOR PERTAHANAN

KABUPATEN/KOTA

BANGKALAN

DAFTAR ISIAN NO 207

NIB:............................

TANAH NEGARA
 SURAT UKUR

NOMOR: .................................................

SEBIDANG TANAH TERLETAK DALAM

Provinsi :.................................................................................................
.........
Kabupaten/
kota :.........................................................................................
Kecamatan :.............................................................................................
.........
Desa/
kelurahan :...........................................................................................
Peta :.................................Nomor Peta Pendaftaran:..............................
Lembar :...............................kotak...........................................................
.......
..................................................................................................................
..............
Keadaan
tamah :............................................................................................
..................................................................................................................
..............
Tanda tanda
batas :.......................................................................................
.................................................................................................................
...............
Luas :......................................................................................................
.............
.................................................................................................................
...............
Penunjukan dan penetapan batas :.......................................................
.................................................................................................................
..............

PENDAFTARAN PERTAMA

a)HAK

NO

Desa/Kel

Tgl.berakhirnya hak

b) NIB

Letak tanah
 c) ASAL HAK

1. Konversi

2.pemberian hak
Tanah negara

3. pemohonan/pemecahan/
Pemisahan/penggabungan bidang

d) DASAR PENDAFTARAN
1. daftar isian no 202

Tgl.

No.

2. surat keputusan
Tgl.
No.
3. permohonan/pemecahan/
Pemisahan/penggabungan bidang
Tgl.
No.

e) SURAT UKUR
tgl.
No.
Luas

i)PETUNJUK

Sebidang tanah negara kelurahan telang kecamatan kamal kabupaten kamal. Yang belum pernah
diuraikan dalam suatu surat ukur/peta bidang (berdasarkan surat pernyataan permohonan bulan november 20220)
bahwa apabila diatas tanah tersebut pernah diterbitkan sertipikat hak atas tanah baik atas nama diri sendiri ataupun
atas nama orang lain,maka saya(pemohon) bersedia untuk dibatalkan dan dicabut hak yang saya mohonkan saat ini.

Penggunaan tanah: untuk lahan pertanian..........................................

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

Daftar isian 302 tgl...................................No.................................................

Daftar isian 307 tgl....................................No................................................

Tanggal permohonan surat ukur.............................................................

Daftar isian 306 tgl. 1-11-21 No

Bangkalan 01 NOV 2021
UNTUK SERTIPIKAT ..............................................................

Kepala seksi survei, pengukuran dan pemetaan

......................................................
Bangkalan,tgl. 3 DES 2021

DAFTAR ISIAN 206

BADAN PERTAHANAN NASIONAL

 SERTIPIKAT
(TANDA BUKTI HAK)

KANTOR PERTAHANAN

KABUPATEN/KOTA

BANGKALAN
......................................................

AK 427616

BADAN PERTAHANAN NASIONAL

 BUKU TANAH
HAK:...................................NO..................................

PROVINSI :..............................................................................................................

KABUPATEN/KOTAMADYA :.................................................................................................................

KECAMATAN :..............................................................................................................

DESA/KELURAHAN :...............................................................................................................

PENDAFTARAN PERTAMA

a. Hak : pakai
No 782/538
Desa telang kecamatan telang

b. Nama jalan
 DAFTAR PERALIHAN HAK,PEMBEBANAN DAN PENCATATAN LAINNYA

SEBAB PERUBAHAN TANGGAL PENDAFTARAN NAMA YANG TANDA TANGAN

NO.DAFTAR ISIAN 301 BERHAK DAN KEPALA KANTOR
NO DAFTAR ISIAN 302 PEMEGANG DAN CAP
LAINNYA KANTOR
....................................... ...................................................
 . .................................................
......................................
 SURAT UKUR
GAMBAR SITUASI
NO...................................................................................................................
....

SEBIDANG TANAH TERLETAK DALAM

PROVINSI:........................................................................................................................................................
..............

KABUPATEN/
MADYA:...........................................................................................................................................

DESA/
RAHAN:...........................................................................................................................................................

PETA:.................................................................................................................................................................
...........................

LEMBAR...........................................kotak........................................................nopendaftaran.........................
...............

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

Keadaan
...................................................................................................................................................................

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

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

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

Tanda tanda
..........................................................................................................................................................

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

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

Luas....................................................................................................................................................................
.....................

............................................................................................................................................................................
.........................
 Penunjukan danpenetapan
.............................................................................................................................

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