Tr. P.U.10/87
KAEDAH-KAEDAH UNDANG-UNDANG PENTADBIRAN KELUARGA ISLAM (BORANG DAN FEE) 1987
JADUAL PERTAMA (Borang 6)
BORANG 6
ENAKMEN UNDANG-UNDANG PENTADBIRAN KELUARGA ISLAM 1985
(Seksyen 21)
PERMOHONAN BERPOLIGAMI
1. Nama ....................................................................... No. K/P ..............................................
2. Tarikh dan tempat lahir ...................................................................
3. Alamat ...........................................................................................
4. Bangsa ........................................... Kewarganegaraan ........................................................
5. Pekerjaan ......................................................... Pendapatan sebulan $ .............................
6. Butir-butir bakal Isteri.
6.1 Nama .................................................................. No. K/P ...........................................
6.2 Tarikh dan tempat lahir ...............................................
6.3 Alamat .............................................................................
6.4 Bangsa ................................... Kewarganegaraan ..................................
6.5 Pekerjaan ............................................... Pendapatan sebulan $ .........................
6.6 Status: dara/ janda/ balu ....................................................................
6.7 Bilangan anak, jika ada (nyatakan: nama, No. K/P dan umur)
(1) .........................................................................
(2) .........................................................................
(3) .........................................................................
(4) .........................................................................
7. Bilangan isteri sekarang ...........................................................................
8. Nama penuh isteri/ isteri-isteri dan alamat:
(1) .......................................................................................
(2) .......................................................................................
(3) .......................................................................................
9. Tarikh dan tempat perkahwinan dengan isteri/isteri-isteri:
(1) .......................................................................................
(2) .......................................................................................
(3) .......................................................................................
10. Bilangan tanggungan* dan keterangan:
(1) .......................................................................................
(2) .......................................................................................
(3) .......................................................................................
(4) ......................................................................................
11. Sebab-sebab permohonan berpoligami .......................................................................................................
Tarikh: H/M .........................................................................................................
Tandatangan Pemohon
12. PENGESAHAN*
Saya .............................................................. mengesahkan segala keterangan yang diberi oleh pemohon ................................. seperti di atas sepanjang pengetahuan saya adalah betul.
Tandatangan ............................
Nama ..........................................
No. K/P ........................................
Alamat .........................................
Pekerjaan ...................................
Tarikh ...........................................
_____________________________________________________________
UNTUK KEGUNAAN PEJABAT SAHAJA
Kebenaran diberi/ tidak diberi untuk ............................................ No. Kad Pengenalan .................................. berkahwin dengan .............................. No. Kad pengenalan .................................................
(METERAI)(...................................)
Tandatangan Hakim Syar'i
Tarikh ...........................................
(Kebenaran ini bagi satu bulan sahaja dari tarikh ia dikeluarkan)____________________________________________________________
*Potong mana yang tidak berkenaan.
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