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
RegencyCity
d. Provinsi
Province
Telepon Phone
Kode Pos Post Code
DusunDukuhKampung Sub Village
Pemohon The Applicant
………………, …………………… Dikeluarkan oleh :
Kepala Dinas Kependudukan dan Pencatatan Sipil
Published by Head of Population and Civil
Registration
………………………………… …………………………………
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
1 0 4
F.1- 58
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 8
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. Antar KabKota Between RegencyCity 2. Antar Provinsi Between Province
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 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
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