DesaKelurahan Village b. Kecamatan District KabKota Provinsi

1 0 5

4. Nama Sponsor

Diisi oleh OA Tinggal Terbatas Sponsor’s name Filled by the foreigner who stay temporary

5. Tipe Sponsor

Diisi oleh OA Tinggal Terbatas Sponsor’s Type Filled by the foreigner who stay temporary

6. Alamat Sponsor

Diisi oleh OA Tinggal Terbatas Sponsor’s Address Filled by the foreigner who stay temporary

a. DesaKelurahan Village b. Kecamatan District

7. Jenis Kepindahan

Diisi oleh OA Tinggal Tetap Kind of Movement Filled by the foreigner who stay permanently

8. Status KK

Bagi Yang Tidak Pindah Diisi oleh OA Tinggal Tetap Family Card Number Status For Those Who Didn’t Move Filled by the foreigner who stay permanently

9. Status KK

Bagi Yang Pindah Diisi oleh OA Tinggal Tetap Family Card Number Status For Those Who Move Filled by the foreigner who stay permanently 1. Kep. Keluarga Head of Family 2. Kep. Keluarga dan Seluruh Angg. Keluarga Head of family and all of the family member 3. Kep. Keluarga dan Sbg. Angg. Keluarga Head of family and some of the family member 4. Angg. Keluarga Family member

1. Numpang KK Join the family card 2. Membuat KK Baru Making the new family card

3. Nomor KK Tetap Permanent family card number

1. Numpang KK Join the family card 2. Membuat KK Baru Making the new family card

3. Nomor KK Tetap Permanent family card number RT

RW

c. KabKota

RegencyCity

d. Provinsi

Province Telepon Phone Kode Pos Post Code DusunDukuhKampung Sub Village Pemohon The Applicant ………………………………… ………………………………… Pelaporan di daerah tujuan paling lambat 30 hari kerja sejak diterbitkannya Surat Keterangan Pindah Datang SKPD di daerah asal. Reporting in the purpose territory not late for 30 workdays from the information moving letter published in the origin territory

10. Keluarga Yang Pindah The Family Who Move

N O. N I K Number of Population Identity N AM A NAME M ASA BERLAK U K I T ASK I T AP sd Expire of TSPCPSPC Until SH DK R of FM

1. Organisasi InternasionalInternational Organization 2. PemerintahGovernment

3. PerusahaanCompany 4. PeroranganPersonal 5. Tanpa SponsorNone ………………, …………………… Dikeluarkan oleh : Kepala Dinas Kependudukan dan Pencatatan Sipil Daerah Asal Published by Head of Population and Civil Registration Origin Territory 1 0 6 Pemohon The Applicant ………………………………… …………………………………… DAT A DAERAH T U J U AN PURPOSE TERRITORY DATA

1. NIK Pemohon Number of Population Identity

2. Nama Pemohon Applicant’s Name

3. Nomor Kartu Keluarga Pemohon Di daerah asal

Diisi oleh OA Tinggal Tetap Family Card number in the Origin territory Filled by the foreigner who stay permanently

4. Nama Kepala Keluarga Pemohon Di daerah asal

Diisi oleh OA Tinggal Tetap Head of Family Name Filled by the foreigner who stay permanently

5. Status KK Bagi Yang Pindah

Diisi oleh OA Tinggal Tetap Card Number Status for the moving one Filled by the foreigner who stay permanently

6. Tanggal Kedatangan Arrival Date

7. Alamat Address

a. DesaKelurahan Village b. Kecamatan District