F-2.

01 PERMENDAGRI 109 TAHUN 2019

Provinsi : SULAWESI SELATAN
Kabupaten/Kota : MAKASSAR
Kecamatan : .................................................................................................................
Desa/Kelurahan : .................................................................................................................
Kode Wilayah : 7371……………….
FORMULIR PELAPORAN PENCATATAN SIPIL DI DALAM WILAYAH NKRI
AKTA KELAHIRAN

Data Pelapor
1. Nomor Induk Kependudukan (NIK) : ...................................................................................................................................................................................
2. Nama Lengkap : ...................................................................................................................................................................................
3. Tempat, Tanggal Lahir : ...................................................................................................................................................................................
4. Pekerjaan : ...................................................................................................................................................................................
5. Nomor Telp. / HP : ...................................................................................................................................................................................
6. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………

I. Data Anak / Bayi

1. Nama Lengkap : ....................................................................................................................................................................................
2. Jenis Kelamin : 1. Laki - Laki 2. Perempuan
3. Tempat di Lahirkan : 1. RS/RB 2. PUSKESMAS 3. POLINDES 4. RUMAH 5. LAINNYA
4. Tempat Kelahiran : ....................................................................................................................................................................................
5. Hari dan Tanggal Lahir : Hari ............................ Tanggal ............... Bulan ............................ Tahun ..........................
6. Pukul : ....................................................................................................................................................................................
7. Jenis Kelahiran : 1. Tunggal 2. Kembar 2 3. Kembar 3 4. Kembar 4 5. Lainnya
8. Kelahiran Ke : .................. (..........................................................................)
9. Penolong Kelahiran : 1. Dokter 2. Bidan/Perawat 3. Dukun 4. Lainnya
10. Berat Bayi : .................. Kg Panjang Bayi : .................. Cm

II. Data Orangtua

Ayah
1. Nomor Induk Kependudukan (NIK) : ....................................................................................................................................................................................
2. Nama Ayah : ....................................................................................................................................................................................
3. Tempat, Tgl Lahir Ayah : ....................................................................................................................................................................................
4. Pekerjaan : ....................................................................................................................................................................................
5. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………
6. Kewarganegaraan Ayah : ....................................................................................................................................................................................
Ibu
7. Nomor Induk Kependudukan (NIK) : ....................................................................................................................................................................................
8. Nama Ibu : ....................................................................................................................................................................................
9. Tempat, Tgl Lahir Ibu : ....................................................................................................................................................................................
10. Pekerjaan : ....................................................................................................................................................................................
11. Alamat : ...................................................................................................................................................................................
Kecamatan : ………………………………………………… Kab/Kota : …………………………………………………
Kelurahan : ………………………………………………… Provinsi : …………………………………………………
12. Kewarganegaraan Ibu : ....................................................................................................................................................................................

13. Nomor Akta Nikah / : ....................................................................................................................................................................................

Akta Perkawinan
14. Tanggal, Bulan dan Tahun Nikah : ....................................................................................................................................................................................
15. Email Ayah / Ibu (*) : ....................................................................................................................................................................................
Aktif dan digunakan
16. Nomor Hp / WA Ayah/Ibu (*) : ....................................................................................................................................................................................
Makassar, ………………………………………………..…..20…….
Nb. Tanda (*) Wajib Isi

Mengetahui : Pelapor
Pejabat Dukcapil Yang Membidangi

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