Anda di halaman 1dari 2

SURAT PERNYATAAN

Yang bertanda tangan di bawah ini, saya :

Nama : ........................................................................................................................
NIK : ........................................................................................................................
Alamat : ........................................................................................................................
........................................................................................................................................

Dengan ini menyatakan bahwa saya pernah menikah secara siri dengan :

Nama : ...................................................................................................................................
NIK : ...................................................................................................................................
Tempat Menikah : ...................................................................................................................................
Tanggal : ...................................................................................................................................

Dengan saksi-saksi:

1. Nama : ........................................................................................................................
NIK : ........................................................................................................................
Alamat : ........................................................................................................................
........................................................................................................................
2. Nama : ........................................................................................................................
NIK : ........................................................................................................................
Alamat : ........................................................................................................................
........................................................................................................................
Wali:

Nama : ........................................................................................................................
NIK : ........................................................................................................................
Alamat : ........................................................................................................................
........................................................................................................................................
Yang menikahkan:

Nama : ........................................................................................................................
NIK : ........................................................................................................................
Alamat : ........................................................................................................................
........................................................................................................................
Demikian pernyataan ini saya buat dengan sebenarnya tanpa paksaan dari manapun. Apabila di
kemudian hari ada permasalahan yang menyangkut masalah ini, saya siap
mempertanggungjawabkannya di hadapan hukum yang berlaku.

Jajag, ........................................
Saya yang menyatakan

Materai 10.000

Mengetahui,

Ketua RT Kepala Desa Jajag

Anda mungkin juga menyukai