DesaKelurahan Village b. Kecamatan District KabKota Provinsi DesaKelurahan Village b. Kecamatan District KabKota Provinsi DesaKelurahan Village b. Kecamatan District

1 0 2 F.1- 57 SU RAT K ET ERAN GAN PI N DAH DATAN G ORAN G ASI N G DALAM WI LAYAH N EGARA K ESAT UAN REPU BLI K I N DON ESI A PROVINSI : PROVINCE KABUPATENKOTA : REGENCY CITY KECAMATAN : DISTRICT DESAKELURAHAN : VILLAGE DUSUNDUKUHKAMPUNG : SUB VILLAGE DAT A DAERAH ASAL ORIGIN TERRITORY DATA

1. NIK Pemohon

Number of Population Identity

2. Nama Lengkap

Full Name

3. Nomor Kartu Keluarga

Diisi oleh OA Tinggal Tetap Family Card Number Filled by the foreigner who stay permanently

4. Nama Kepala Keluarga

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

5. Alamat

Address

a. DesaKelurahan Village b. Kecamatan District

RT RW

c. KabKota

RegencyCity

d. Provinsi

Province Telepon Phone Kode Pos Post Code

6. Nomor Tgl KITASKITAP

Number and date of TSPC PSPC DusunDukuhKampung Sub Village F.1 -5 7 INFORMATION LETTER OF THE FOREIGNER MOVING INTO THE UNITY STATE OF INDONESIAN REPUBLIC N O: …………………………………. DAT A K EPI N DAH AN THE MOVEMENT DATA

1. Alasan Pindah

The Reason of Moving

2. Alamat Tujuan Pindah

Destination Moving Address

a. DesaKelurahan Village b. Kecamatan District

3. Klasifikasi Pindah

Moving Clasification

1. Pekerjaan Occupation

3. Keamanan Security 5. Perumahan Housing 7. Lainnya sebutkan 2.

Pendidikan Education 4. Kesehatan Healthy 6. Keluarga Family Other mention

1. Dalam satu DesaKelurahan In One Village 2. Antar DesaKelurahan Between Village

3. Antar Kecamatan Between District RT

RW

c. KabKota

RegencyCity

d. Provinsi

Province Telepon Phone Kode Pos Post Code DusunDukuhKampung Sub Village Kop Dinas Kependudukan dan Pencatatan Sipil 1 0 3

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