Family Card

 

K. XXXXXXXXX

FAMILY CARD No. XXXXXXXXXX

 

: : : :

District Regency/Municipality Postal Code Province

: : : :

 Name of Family Head Address  Neighborhood/Hamlet Village/Urban Village

  No

Full Name

NIK

Sex

Place of Birth

Date of Birth

Religion

Education

Occupation

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

1 2 3 4 5 6 7 8

Immigration Documents No

Marital Status

Family Relationship

Citizenship

1 2 3 4 5 6 7 8 9 10

(9)

(10)

(11)

Issued on

:

Sheet      

: : : :

  I II III IV

Family Head Neighborhood Village/Urban Village District

Name of Parents

Passport No.

KITAS/KITAP No.

Father

Mother

(12)

(13)

(14)

(15)

FAMILY HEAD

HEAD OF THE POPULATION AND CIVIL REGISTRATION DEPARTMENT

Signed xxxxxxxxxxxxxx Signature/Thumb Imprint

Signed and Stamped XXXXXXXX  NIP. XXXXXXXX

 

 

 

K. XXXXXXXXX

KARTU KELUARGA No. XXXXXXXXXX

 

: : : :

Kecamatan Kabupaten/Kota Kode Pos Provinsi

: : : :

 Name Kepala Keluarga Alamat RT/RW Desa/Kelurahan

  No

Nama Lengkap

NIK

Jenis Kelamin

Tempat Lahir

Tanggal Lahir

Agama

Pendidikan

Jenis Pekerjaan

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

1 2 3 4 5 6 7 8

Dokumen Imigrasi No

Status Perkawinan

Status Hubungan Dalam Keluarga

Kewarganegaraan Kewarganegaraan

1 2 3 4 5 6 7 8 9 10

(9)

(10)

(11)

Dikeluarkan

:

Tanggal LEMBAR      

: : : :

  I II III IV

Kepala Keluarga RT Desa/Kelurahan Kecamatan

Name Orang Tua

No. Paspor

No. KITAS/KITAP

Ayah

Ibu

(12)

(13)

(14)

(15)

KEPALA KELUARGA

Signed xxxxxxxxxxxxxx Tanda Tangan/Cap Jempol

Kepala Dinas Kependudukan dan Catatan Sipil Tanda Tangan dan Cap XXXXXXXX  NIP. XXXXXXXX