N2

Lampiran 8 PMA No. 2 Tahun 1990

                                                                                             Pasal 8 ayat (1) huruf a

                                                                                                                       

 Model N2

KANTOR DESA / KELURAHAN     : .............................................................................

KECAMATAN                                   : .............................................................................

KABUPATEN / KOTA                      : .............................................................................

SURAT KETERANGAN  ASAL - USUL

Nomor : ......................................................

Yang bertanda di bawah ini menerangkan dengan sesungguhnya bahwa :

I.     1. Nama lengkap dan alias                            :  .............................................................................

2. Tempat dan tanggal lahir                           :  .............................................................................

3. Warga Negara                                           :  .............................................................................

4. Agama                                                      :  .............................................................................

5. Pekerjaan                                                  :  .............................................................................

6. Tempat tinggal                                          :  .............................................................................

Adalah benar anak kandung dari pernikahan seorang pria :

II.  1. Nama lengkap dan alias                            :   .............................................................................

2. Tempat dan tanggal lahir                           :   .............................................................................

3. Warga Negara                                           :   .............................................................................

4. Agama                                                      :   .............................................................................

5. Pekerjaan                                                  :   .............................................................................

6. Tempat tinggal                                          :   .............................................................................

       

Dengan seorang wanita :

1. Nama lengkap dan alias                            :  .............................................................................

2. Tempat dan tanggal lahir                           :  .............................................................................

3. Warga Negara                                           :  .............................................................................

4. Agama                                                      :  .............................................................................

5. Pekerjaan                                                  :  .............................................................................

6. Tempat tinggal                                          :  .............................................................................

Demikianlah surat keterangan ini dibuat dengan mengingat sumpah jabatan dan untuk digunakan seperlunya.

		Kediri,............................
*) nama terang		Kepala Desa/Lurah         ..................................... ................................................ Donwload