<table style="border-collapse: collapse; width: 100%;" border="0">
<tbody>
<tr>
<td style="width: 6.78314%;">Nomor</td>
<td style="width: 1.95177%; text-align: center;">:</td>
<td style="width: 91.2651%;">[Format_nomor_suraT]</td>
</tr>
<tr>
<td style="width: 6.78314%;">Perihal</td>
<td style="width: 1.95177%; text-align: center;">:</td>
<td style="width: 91.2651%;">
<h4 style="margin: 0px; text-align: left;"><span style="text-decoration: underline;">[JUdul_surat]</span></h4>
</td>
</tr>
</tbody>
</table>
<p style="margin: 0px; text-align: justify;"><br>Kepada Yth<br><br>Kepala Pengadilan Agama<br>[SeButan_kabupaten] [NaMa_kabupaten]<br><br></p>
<p style="text-align: justify; text-indent: 30px;">Yang bertanda tangan di bawah ini [JaBatan] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten], Provinsi [NaMa_provinsi] menerangkan dengan sebenarnya bahwa :</p>
<table style="border-collapse: collapse; width: 100%; height: 108px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">1.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Nama Lengkap</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;"><strong>[NAma]</strong></td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">2.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">NIK / No. KTP</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Nik]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">3.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[TtL]</td>
</tr>
<tr style="height: 36px;">
<td style="width: 4.31655%; text-align: center; height: 36px;"> </td>
<td style="width: 3.90429%; height: 36px; text-align: left;">4.<br><br></td>
<td style="width: 30.5253%; text-align: left; height: 36px;">Alamat / Tempat Tinggal<br><br></td>
<td style="width: 1.2333%; text-align: center; height: 36px;">:<br><br></td>
<td style="width: 60.0206%; height: 36px; text-align: justify;">[AlamaT] [Sebutan_desa] [NaMa_desa], Kecamatan [NaMa_kecamatan], [SeButan_kabupaten] [NaMa_kabupaten]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">5.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Pekerjaan</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[PeKerjaan]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Mengajukan permohonan untuk diterbitkan penetapan Pengadilan Negeri sebagai persyaratan pencatatan peristiwa kelahiran dan penerbitan kutipan Akta Kelahiran atas nama:</p>
<table style="border-collapse: collapse; width: 100%; height: 90px;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">6.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Nama</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Form_nama_anaK]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">7.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Tempat / Tanggal Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Form_tempat_lahiR], [Form_tanggal_lahiR]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">8.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Hari Lahir</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Form_hari_lahiR]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">9.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Alamat</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Form_alamat_anaK]</td>
</tr>
<tr style="height: 18px;">
<td style="width: 4.31655%; text-align: center; height: 18px;"> </td>
<td style="width: 3.90429%; height: 18px; text-align: left;">10.</td>
<td style="width: 30.5253%; text-align: left; height: 18px;">Nama Ayah</td>
<td style="width: 1.2333%; text-align: center; height: 18px;">:</td>
<td style="width: 60.0206%; height: 18px; text-align: justify;">[Form_nama_ayaH]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center;"> </td>
<td style="width: 3.90429%; text-align: left;">11.</td>
<td style="width: 30.5253%; text-align: left;">Nama Ibu</td>
<td style="width: 1.2333%; text-align: center;">:</td>
<td style="width: 60.0206%; text-align: justify;">[Form_nama_ibU]</td>
</tr>
<tr>
<td style="width: 4.31655%; text-align: center;"> </td>
<td style="width: 3.90429%; text-align: left;">12.</td>
<td style="width: 30.5253%; text-align: left;">Alamat Orang Tua</td>
<td style="width: 1.2333%; text-align: center;">:</td>
<td style="width: 60.0206%; text-align: justify;">[Form_alamat_orang_tuA]</td>
</tr>
</tbody>
</table>
<p style="text-align: justify; text-indent: 30px;">Demikian surat keterangan ini dibuat dengan sebenarnya, untuk dipergunakan sebagaimana mestinya.</p>
<p> </p>
<table style="border-collapse: collapse; width: 100%;" border="0">
<tbody>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[NaMa_desa], [TgL_surat]</td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Atas_namA]</td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"><br><br><br><br></td>
<td style="width: 35%;"> </td>
</tr>
<tr>
<td style="width: 35%; text-align: center;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[Nama_pamonG]</td>
</tr>
<tr>
<td style="width: 35%;"> </td>
<td style="width: 30%;"> </td>
<td style="width: 35%; text-align: center;">[SEbutan_nip_desa] : [nip_pamong]</td>
</tr>
</tbody>
</table>
<div style="text-align: center;"><br>[qr_code]</div>