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Lampiran XII

Keputusan Dirjen Bimas Islam No. 473 Tahun 2020

FORMULIR PEMERIKSAAN NIKAH


Model N8

PEMERIKSAAN NIKAH
Nomor :................./………………../............./....................

Pada hari ini ................................... tanggal ................................................bulan ...................................................


tahun ................................................................bertempat di KUA Kecamatan/KBRI/KJRI .......................................
Kabupaten / Kota ........................................ Provinsi ................................................ telah dilakukan pemeriksaan
nikah terhadap :

1. Nama Calon Suami : .........................................................................................................


2. Nama Calon Istri : .........................................................................................................
3. Nama Wali : .........................................................................................................
4. Rencana akad nikah :
a. Hari/tanggal : ............................................................................................. Masehi
............................................................................................ Hijriyah
b. Waktu : ...............................................................................................................
c. Tempat akad nikah : .........................................................................................................
...............................................................................................................
5. Nama Petugas Pemeriksa : ...............................................................................................................
NIP : .........................................................................................................
Jabatan : .........................................................................................................

................................,.......................................20
Petugas

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

Catatan :
Nomor urut pendaftaran/nomor Provinsi.nomor kabupaten/kota.nomor kecamatan.nomor kelurahan/
desa/bulan/tahun.

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