<page orientation="portrait" format="210x330" style="font-size: 10pt">

    <!-- Judul Lampiran -->
    <table align="right">
        <tr>
            <td colspan="10">Lampiran V</td>
        </tr>
        <tr>
            <td colspan="10">Kepdirjen Bimas Islam Nomor 473 Tahun 2020</td>
        </tr>
        <tr>
            <td colspan="10">Tentang</td>
        </tr>
        <tr>
            <td colspan="10">Petunjuk Teknis Pelaksanaan Pencatatan Nikah</td>
        </tr>
        <tr>
            <?php for ($i = 0; $i < 48; $i++) : ?>
                <td>&nbsp;</td>
            <?php endfor; ?>
        </tr>
    </table>

    <!-- Model N4 -->
    <table align="right">
        <tr>
            <td><strong>Model N1</strong></td>
            <td colspan="30">&nbsp;</td>
        </tr>
    </table>

    <table id="kop" class="disdukcapil">
        <col span="48" style="width: 2.0833%;">
        <tr>
            <td colspan="48">&nbsp;</td>
        </tr>
        <tr>
            <td colspan="17">KANTOR DESA/KELURAHAN</td>
            <td>: </td>
            <td colspan="30">[NAma_desa]</td>
        </tr>
        <tr>
            <td colspan="17">KECAMATAN</td>
            <td>: </td>
            <td colspan="30">[NAma_kecamatan]</td>
        </tr>
        <tr>
            <td colspan="17">KABUPATEN/KOTA</td>
            <td>:</td>
            <td colspan="30">[NAma_kabupaten]</td>
        </tr>
        <tr>
            <?php for ($i = 0; $i < 48; $i++) : ?>
                <td>&nbsp;</td>
            <?php endfor; ?>
        </tr>
    </table>

    <p style="margin: 0; text-align: center;" class="title"><u>PENGANTAR NIKAH</u></p>
    <p style="margin: 0; text-align: center;">Nomor : [FOrmat_nomor_surat]</p>

    <p>Yang bertanda tangan dibawah ini menjelaskan dengan sesungguhnya bahwa : </p>
    <table id="kop" class="disdukcapil">
        <col span="48" style="width: 2.0833%;">
        <tr>
            <td colspan="48">&nbsp;</td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">1. Nama</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma]</strong></td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">2. Nomor Induk Kependudukan (NIK)</td>
            <td>: </td>
            <td colspan="27">[NiK]</td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">3. Jenis Kelamin</td>
            <td>: </td>
            <td colspan="27">[JeNis_kelamin]</td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">4. Tempat dan Tanggal Lahir</td>
            <td>: </td>
            <td colspan="27">[TtL]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">5. Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WaRga_negara]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">6. Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">7. Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">8. Pendidikan Terakhir</td>
            <td>: </td>
            <td colspan="27">[PeNdidikan_kk]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">9. Bin/Binti</td>
            <td>: </td>
            <td colspan="27">[Form_bin_priA]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">10. Alamat</td>
            <td>: </td>
            <td colspan="27">[AlAmat]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">11. Status Perkawinan</td>
            <td>: </td>
            <td colspan="27"></td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">
                <table>
                    <tr>
                        <td>&nbsp;&nbsp;&nbsp;</td>
                        <td>a. </td>
                        <td>Jejaka, Duda atau beristri ke [Form_istrikE]</td>
                    </tr>
                </table>
            </td>
            <td>: </td>
            <td colspan="27">[Form_status_kawin_priA]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">
                <table>
                    <tr>
                        <td>&nbsp;&nbsp;&nbsp;</td>
                        <td>b. </td>
                        <td>Perempuan : Perawan, Janda</td>
                    </tr>
                </table>
            </td>
            <td>: </td>
            <td colspan="27">-</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">12. Nama istri / suami terdahulu</td>
            <td>: </td>
            <td colspan="27">[NAma_dst]</td>

        </tr>
    </table>

    <p>Adalah benar-benar anak dari perkawinan seorang pria :</p>
    <table id="kop" class="disdukcapil">
        <col span="48" style="width: 2.0833%;">
        <tr>
            <td colspan="48">&nbsp;</td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Nama Lengkap dan alias</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma_dapp]</strong></td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Nomor Induk Kependudukan (NIK)</td>
            <td>: </td>
            <td colspan="27">[NiK_dapp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Tempat dan Tanggal Lahir</td>
            <td>: </td>
            <td colspan="27">[TtL_dapp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WaRga_negara_dapp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma_dapp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan_dapp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Alamat</td>
            <td>: </td>
            <td colspan="27">[AlAmat_dapp]</td>

        </tr>
    </table>
    <p>dengan seorang wanita :</p>
    <table id="kop" class="disdukcapil">
        <col span="48" style="width: 2.0833%;">
        <tr>
            <td colspan="48">&nbsp;</td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Nama Lengkap dan alias</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma_dipp]</strong></td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Nomor Induk Kependudukan (NIK)</td>
            <td>: </td>
            <td colspan="27">[NiK_dipp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Tempat dan Tanggal Lahir</td>
            <td>: </td>
            <td colspan="27">[TtL_dipp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WaRga_negara_dipp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma_dipp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan_dipp]</td>

        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">Alamat</td>
            <td>: </td>
            <td colspan="27">[AlAmat_dipp]</td>

        </tr>
    </table>
    <p>Demikian surat pengantar ini dibuat dengan mengingat sumpah jabatan dan untuk
        dipergunakan sebagaimana mestinya.</p>

    <!-- Penandatangan -->
    <br><br><br>
    <table style="border-collapse: collapse; width: 100%; height: 144px;" border="0">
    <tbody>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;"> </td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;">[NAma_desa], [TgL_surat]</td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;"> </td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;">[Atas_namA]</td>
    </tr>
    <tr style="height: 72px;">
    <td style="width: 26.6281%; text-align: center; height: 72px;">[qr_code]</td>
    <td style="width: 2.75528%; height: 72px;"><br><br><br><br></td>
    <td style="width: 70.6166%; height: 72px;"> </td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;"> </td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;">[NAma_pamonG]</td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; height: 18px;"> </td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;"> </td>
    </tr>
    </tbody>
    </table>
</page>