Form 4. (THE ADMINISTRATION OF SYARIAH LAW WORK PROCEDURE MANNUAL, DEPARTMENT OF ISLAMIC FOR PERLIS (PROCEDURE AND FORM 1995)

Ps. P.U. 6/95
THE ADMINISTRATION OF SYARIAH LAW WORK PROCEDURE MANNUAL, DEPARTMENT OF ISLAMIC FOR PERLIS (PROCEDURE AND FORM 1995)

Form 4.

(JAIPs. 4)

DEPARTMENT OF ISLAMIC AFFAIRS STATE OF PERLIS
(THE ADMINISTRATION OF SYARIAH LAW DIVISION) 01000 KANGAR

Ref. No: .............................

APPLICATION FOR "TEBUS TALAK" (KHULUK)

Wife's Declaration

Name: .............................................................................................................................
NRIC No: ................................................................. Age: ...............................................
Occupation: .............................................. Income: .........................................................
Address: .........................................................................................................................

I hereby declare that the particulars below are true:

(A) 1. I have married/reconcilied on ..................................................................... at Pejabat Kadi ........................................ State ................... vide certificate of marriage/reconciliation No ..........................................

2. The situation of my household is ....................................................................................

3. I hereby apply for ..........................................................................................................

4. Conditions of divorce .....................................................................................................

5. Reason for applying ......................................................................................................

6. I have field a complaint at the Administration of Syariah Law Division on ..................... and have met ................................. times for purposes of effecting a reconciliation but have failed.

7. I have ........................................... child/children.

	Name	Age

(a)	.............................................................................................	.............................
(b)	.............................................................................................	.............................
(c)	.............................................................................................	.............................
(d)	.............................................................................................	.............................
(e)	.............................................................................................	.............................

(B) Custody of child/children.

1. .............................................................. child/children to be in the custody of the wife.

2. .............................................................. child/children to be in the custody of the husband.

(C) Claims.

1. Maintenance for children in the sum of RM ...................... a month for ................... number of children in the custody of the wife.

2. Maintenance for wife under "eddah" in the sum of RM ................................ a month/for the duration of "eddah".

3. "Mutaah" (compensation) ...............................................................................................

4. Jointly owned assets.
(a) House ..........................................................................................................................
(b) Land ............................................................................................................................
(c) Furniture ......................................................................................................................
(d) Others .........................................................................................................................

5. Agreement.
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

I hereby declare that I have supplied all the information above voluntarily and without any force from any party.

Date: .................................	Signature:: .............................
	Name: ...................................

(STATEMENT BY CONSULTANT OFFICER)
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................

Date: .................................	Signature:: .............................
	Name: ...................................