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Lampiran XIII

Keputusan Dirjen Bimas Islam No. 473 Tahun 2020

FORMULIR PENGUMUMAN NIKAH


Model N 9

KANTOR URUSAN AGAMA


KECAMATAN .................................................
KABUPATEN/KOTA .................................................

PENGUMUMAN NIKAH
Nomor Pemeriksaan: ........../…………………./............./............

1. CALON PENGANTIN LAKI-LAKI


Nama : ..............................................................................................
Bin : ...............................................................................................
Nomor Induk Kependudukan : ...............................................................................................
Tempat dan tanggal lahir :................................................................................................
Kewarganegaraan : ...............................................................................................
Agama : ...............................................................................................
Pekerjaan : ...............................................................................................
Alamat : ...............................................................................................

2. CALON PENGANTIN WANITA


Nama : ..............................................................................................
Binti : ...............................................................................................
Nomor Induk Kependudukan : ...............................................................................................
Tempat dan tanggal lahir :................................................................................................
Kewarganegaraan : ...............................................................................................
Agama : ...............................................................................................
Pekerjaan : ...............................................................................................
Alamat : ...............................................................................................

3. WALI NIKAH
Nasab/Hakim : ...............................................................................................
Sebab : ...............................................................................................
Nama : ..............................................................................................
Bin : ...............................................................................................
Nomor Induk Kependudukan : ...............................................................................................
Tempat dan tanggal lahir :................................................................................................
Kewarganegaraan : ...............................................................................................
Agama : ...............................................................................................
Pekerjaan : ...............................................................................................
Alamat : ...............................................................................................

4. HARI, TANGGAL, TEMPAT NIKAH


Hari : ...............................................................................................
Tanggal : ...............................................................................................
Tempat : ..............................................................................................

Kepala /Penghulu/PPN LN*)

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

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