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DATA SAKSI
Nomor Perkara : ............. / Pdt..... / ............./ PA....
SAKSI I (SATU)
Nama : ...........................................................................................................
: bin/binti* ...........................................................................................
Tempat & Tanggal lahir : ..................................... , ....................................................................
Umur : ......................... tahun
No. Identitas (KTP/SIM) : ...........................................................................................................
No. Telephone : ...........................................................................................................
Jenis Kelamin : ...........................................................................................................
Pendidikan : ...........................................................................................................
Agama : ...........................................................................................................
Pekerjaan : ...........................................................................................................
Alamat : Jalan .................................................................................................
Dusun/Dukuh ....................................................................................
RT. ............. RW. ............ Desa / Kel ...................................................
Status Kawin : Belum Kawin / Kawin / Duda / Janda *
Status Saksi Sebagai : Ayah / Ibu / Tetangga / Saudara / Saksi Ahli KUA / ......................*
Dari pihak Pemohon / Penggugat / Termohon / Tergugat *
SAKSI II (DUA)
Nama : ...........................................................................................................
: bin/binti* ...........................................................................................
Tempat & Tanggal lahir : ..................................... , ....................................................................
Umur : ......................... tahun
No. Identitas (KTP/SIM) : ...........................................................................................................
No. Telephone : ...........................................................................................................
Jenis Kelamin : ...........................................................................................................
Pendidikan : ...........................................................................................................
Agama : ...........................................................................................................
Pekerjaan : ...........................................................................................................
Alamat : Jalan .................................................................................................
Dusun/Dukuh ....................................................................................
RT. ............. RW. ............ Desa / Kel ...................................................
Status Kawin : Belum Kawin / Kawin / Duda / Janda *
Status Saksi Sebagai : Ayah / Ibu / Tetangga / Saudara / Saksi Ahli KUA / ......................*
Dari pihak Pemohon / Penggugat / Termohon / Tergugat *
(*Coret yang tidak perlu)
Wajib melampirkan fotocopy KTP / SIM / Identitas lainnya Tanggal ........................
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