K.

XXXXXXXXX
FAMILY CARD
No. XXXXXXXXXX
Name of Family Head : District :
Address : Regency/Municipality :
Neighborhood/Hamlet : Postal Code :
Village/Urban Village : Province :

No Full Name NIK Sex Place of Birth Date of Birth Religion Education Occupation

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Immigration Documents Name of Parents

No Marital Status Family Relationship Citizenship
Passport No. KITAS/KITAP No. Father Mother
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Issued on : FAMILY HEAD HEAD OF THE POPULATION AND CIVIL

Sheet : I Family Head REGISTRATION DEPARTMENT
: II Neighborhood
: III Village/Urban Village Signed Signed and Stamped
: IV District xxxxxxxxxxxxxx XXXXXXXX
Signature/Thumb Imprint NIP. XXXXXXXX
 K. XXXXXXXXX
KARTU KELUARGA
No. XXXXXXXXXX
Name Kepala Keluarga : Kecamatan :
Alamat : Kabupaten/Kota :
RT/RW : Kode Pos :
Desa/Kelurahan : Provinsi :

No Nama Lengkap NIK Jenis Kelamin Tempat Lahir Tanggal Lahir Agama Pendidikan Jenis Pekerjaan

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2
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5

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Dokumen Imigrasi Name Orang Tua

No Status Perkawinan Status Hubungan Dalam Keluarga Kewarganegaraan
No. Paspor No. KITAS/KITAP Ayah Ibu
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Dikeluarkan : KEPALA KELUARGA Kepala Dinas Kependudukan dan Catatan Sipil

Tanggal
LEMBAR : I Kepala Keluarga Tanda Tangan dan Cap
: II RT Signed XXXXXXXX
: III Desa/Kelurahan xxxxxxxxxxxxxx NIP. XXXXXXXX
: IV Kecamatan Tanda Tangan/Cap Jempol