Pada hari ini, ............... tanggal ...... bulan .......................... tahun ........... bertempat di .................. ,
saya:
Nama lengkap : .......................................................................................................
NIK : .......................................................................................................
Nomor KK : .......................................................................................................
Tempat & tanggal lahir / umur : .................................................................................. / ..................
Pekerjaan : .......................................................................................................
Alamat : .......................................................................................................
.......................................................................................................
Memberikan kuasa pengasuhan anak/anak perwalian saya atas nama:
Nama : .......................................................................................................
NIK : .......................................................................................................
Kepada:
Nama : .......................................................................................................
NIK : .......................................................................................................
Nomor KK : .......................................................................................................
Demikian surat kuasa ini dibuat dengan sebenar-benarnya dan untuk digunakan sebagai
persyaratan pengurusan dokumen kependudukan.
(........................................................................ ) ( ....................................................................... )