- 32 -

F O R M U L IR P E N D A F T A R A N P E R P IN D A H A N P E N D U D U K F - 1 .0 3
P e r h a tia n :
H a r a p d iis i d e n g a n h u r u f c e t a k d a n m e n g g u n a k a n tin t a h ita m

11. NoKK

2. N am a L eng kap P e m o h o n
I 3. NIK
4 . Je n is P e rm o h o n a n
I
[] D. SURAT KETERANG AN K EPEN DUDUK AN
□ S u ra t K e te ra n g a n P in d a h
[ I S u ra t K e te ra n g a n P in d a h L u a r N e g e ri (S K P L N )
[ j S u ra t K e te ra n g a n T e m p a t T in g g a l (S K T T )
B a g i O ra n g A s in g T in g g a l T e rb a ta s

5. A la m a t A s a l H: c
b. K e c a m a ta n
I I l~l /|_ _ L. I_ _ I
a . D e s a /K e lu r a h a n [_
c . K a b u p a te n /K o ta [ d. P ro v in s i
Kode Pos m r r~r jj
l | D a la m s a tu d e s a /k e lu ra h a n a ta u y a n g d is e b u t d e n g a n n a m a la in

n A n ta r d e s a /k e lu ra h a n a ta u y a n g d is e b u t d e n g a n n a m a la in d a la m s a tu k e c a m a ta n

l A n ta r k e c a m a ta n a ta u y a n g d is e b u t d e n g a n n a m a la in d a la m s a tu k a b u p a te n /k o ta ;

□ A n ta r k a b u p a te n /k o ta d a la m s a tu p ro v in s i

□ A n ta r p ro v in s i

7. A la m a t P in d a h RT l I I rw i i r~ i
a . D e s a /K e lu r a h a n |_ b. K e c a m a ta n
c . K a b u p a te n /K o ta Q d. P ro v in s i
Kode P os I I i i i
| 8.1 A la s a n P in d a h |:| | P e k e rja a n ~ IK e a m a n a n | P e ru m a h a n 1L a in n y a (s e b u tk a n )

I I P e n d id ik a n I | K e s e h a ta n | | K e lu a rg a □ .........
1 9 . Je n is K e p in d a h a n |:| 1 K e p a la K e lu a rg a [ K e p a la K e lu a rg a d a n S e b a g ia n A n g g o ta K e lu a rg a
□ K e p a la K e lu a rg a d a n S e lu ru h A n g g o ta K e lu a rg a 1 |A n g g o ta K e lu a rg a

10. A n g g o ta K e lu a rg a : |____ | N u m p a n g K K I I M e m b u a t K K B a ru
T id a k P in d a h
11. A n g g o ta K e lu a rg a :| | N um pang KK I I M e m b u a t K K B a ru
ya n g P in d a h
|12. D a fta r A n g g o ta K e lu a rg a y a n g P in d a h
■f * m N A M A L E N G K A P *5

Z]
m
 - 33 -

D i i s i o l e h P e n d u d u k ( O r a n g A s i n g ) p e m e g a n g IT A S y a n g M e n g a j u k a n S K T T d a n O A P e m e g a n g IT A P y a n g M e n g a j u k a n S u r a t K e t e r a n g a n K e p e n d u d u k a n L a i n n y a

|13. Nama Sponsor |: ------------------------------------------------------------------------------------------------------------------------------------ !

|14. Tipe Sponsor I: I Organisasi Internasional I I Pemerintah | | Perusahaan
| Perorangan | | Tanpa Sponsor
|15. Alamat Sponsor I: I

16. Nomor dan Tanggal :

KITAS & KiTAP
Nomor Tanggal Masa Berlaku
D iisi o l e h P e n d u d u k y a n g M e n g a ju k a n S u r a t K e t e r a n g a n P in d a h L u a r N e g e r i

|17. Negara Tujuan 1: 1 I I I I

kode negara
118. AlamatTuiuan |: | I

119. Penanggung Jawab I: I ___________________________________________

|20. Rencana Pindah Tanggal I: Tgl. I I I Bin. I I I Thn.l I I I |

M e n g e ta h u i, ..................................................................................................

Kepala Dinas /Suku Dinas/UPT Dinas Pemohon,

Kependudukan dan Pencatatan Sipil

(............................................................... )