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



Borang 1.

(JAIPs. 1)

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

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

PERMOHONAN UNTUK BERCERAI
Pengakuan Suami/lsteri

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

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

Bahawa kami mengaku dengan sesungguhnya perkara-perkara yang kami nyatakan di bawah ini:

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

2. Kami memohon untuk bercerai secara baik (Sulh).

3. Alasan permohonan ....................................................................................................

4. Kami telah mengadu di Bahagian Pentadbiran Undang-undang Syariah pada .................. dan telah mengadakan ............................ kali perundingan tetapi gagal untuk berdamai.

5. Kami 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 kami diatas adalah secara sukarela dan tanpa apa-apa paksaan dari mana-mana pihak.

Tandatangan: ................................................ Tandatangan ......................................
Nama: ..........................................................Nama: ...............................................
(Suami)
(Isteri)
Tarikh: ...........................................................Tarikh: ...............................................

(KENYATAAN PEGAWAI PERUNDING)
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................

Tarikh: .................................Tandatangan: .............................
Nama: .......................................
_________________________________________________________________________________
Peringatan: Tandatangan hendaklah dibuat di hadapan Pegawai Perunding


Copyright © PNMB-LawNet. All rights reserved.