Borang 5. (MANUAL PROSEDUR KERJA PENTADBIRAN UNDANG-UNDANG SYARIAH, JABATAN HAL EHWAL AGAMA ISLAM PERLIS (ACARA DAN BORANG 1995)

Ps. P.U. 6/95
MANUAL PROSEDUR KERJA PENTADBIRAN UNDANG-UNDANG SYARIAH, JABATAN HAL EHWAL AGAMA ISLAM PERLIS (ACARA DAN BORANG 1995)

Borang 5.

(JAIPs. 5)

JABATAN HAL EHWAL AGAMA ISLAM NEGERI PERLIS
(BAHAGIAN PENTADBIRAN UNDANG-UNDANG SYARIAH) 01000 KANGAR

No. Rujukan: .......................

PENGAKUAN LAFAZ CERAI/KERAGUAN MENGENAI PERCERAIAN

Pengakuan Suami/Isteri

Nama: .........................................................................................................................
No. K/P: ...................................................... Umur: .....................................................
Pekerjaan: ................................................. Pendapatan: ..............................................
Alamat tempat tinggal ...................................................................................................

Bahawa saya mengakui dengan sesungguhnya perkara-perkara yang saya nyatakan di bawah ini:

(A) 1. Saya telah berkahwin/rujuk pada ............................... di Pejabat Kadi ............................ Negeri ................................................ Bil. Sijil Nikah/Rujuk ..................................................

2. Keadaan rumahtangga saya ..............................................................................................

3. Saya/suami saya telah menjatuhkan talak terhadap isteri saya/saya ....................................
No. K/P: .................................... yang tinggal di alamat ........................................................

4. Saya/suami saya ................................................ alamat ................................................ telah melafazkan ............................................ pada ..................... jam ........................ siang/malam di alamat ................................................... di hadapan isteri/saya

5. Saya mempunyai ....................... orang anak.

	Nama	Umur

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

(B) Penjagaan Anak.

1. ......................................... orang di bawah jagaan isteri.

2. ......................................... orang di bawah jagaan suami.

(C) Tuntutan-tuntutan.

1. Nafkah anak .......................... sebulan untuk ................. orang anak di bawah jagaan isteri.

2. Nafkah eddah ............................... sebulan/selama eddah.

3. Mutaah (saguhati perceraian) ...........................................................................................

4. Harta sepencarian.
(a) Rumah .........................................................................................................................
(b) Tanah ..........................................................................................................................
(c) Perabot ........................................................................................................................
(d) Lain-lain .......................................................................................................................

5. Lain-lain tuntutan (termasuk hutang)
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

6. Perjanjian.
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

Semua keterangan saya diatas adalah secara sukarela dan tanpa apa-apa paksaan dari mana-mana pihak.

Tarikh: .................................	Tandatangan: .............................
	Nama: .......................................

(KENYATAAN PEGAWAI PERUNDING)
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Tarikh: .................................	Tandatangan: .............................
	Nama: .......................................

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Peringatan: Tandatangan hendaklah dibuat di hadapan Pegawai Perunding