SURAT KETERANGAN NIKAH SIRI

 

SURAT KETERANGAN NIKAH SIRRI

 

Yang bertanda tangan di bawah ini, saya :

 

                                                Nama                         : ................................................................................

Umurt/Tgl. Lahir       : ................................................................................

Agama                       : ................................................................................

Pekerjaan                  : ................................................................................

Alamat                        : ................................................................................

                                    : ................................................................................

Pada hari ini ................... Tanggal ............. Bulan ............................Tahun ............ telah melaksanakan Akad Nikah Siri dengan seorang wanita di bawah ini :

 

                                                Nama                         : ................................................................................

Umurt/Tgl. Lahir       : ................................................................................

Agama                       : ................................................................................

Pekerjaan                  : ................................................................................

Alamat                        : ................................................................................

                                    : ................................................................................

Yang di waleni oleh ....................................... bernama : .................................................................... Dengan mas kawin .........................................................................................................dibayar kontan.

Demikian pernyataan ini saya buat dengan sebenarnya, tanpa ada unsur paksaan dari pihak manapun dan pihak siapapun.

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

SUAMI           ...............................................	ISTRI           ...............................................			WALI           ...............................................
SAKSI I           ...............................................			SAKSI II           ...............................................