Translation of KARTU KELUARGA

(Family Registers)
No. 3526031204062401

Name of Head of Family : SURATNO , S.Pd District : BURNEH

Address : DSN. DEMANGAN City : BANGKALAN
Neighborhood Ward : 005 / 006 Postal Code : 69121
Village Administrative Unit : TUNJUNG Province : JAWA TIMUR (EAST JAVA)

Place of
No Full Name Citizen Number Sex Date of Birth Religion Education Occupation
Birth
(1) (2) (3) (4) (5) (6) (7) (8)
1
2
3
4
5
6

Immigration Document Parents

No Marital Status Relation Nationality Passport KITAS Number
Father Mother
Number /KITAP
(9) (10) (11) (12) (13) (14) (15)
1
2
3
4
5
6

Issued on : 25-05-2009 Head of Family Head of Department of Population and

Copy : I. Head of Family Civil Registration
II. RT (Neighborhood Ward)
III. Sub District Signed Signed
IV. District
SURATNO , S.Pd Drs. H. MOH. SJAFII, MM
signature / thumbprint NIP. 195602111980031010