Borang 4. (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 4.

(JAIPs. 4)

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

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

PERMOHONAN TEBUS TALAK (KHULUK)
Pengakuan Suami/Isteri

Nama: .........................................................................................................................
No. K/P: ...................................................... Umur: .............................................tahun
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 memohon .................................................................................................................

4. Syarat perceraian ..............................................................................................................

5. Alasan permohonan ...........................................................................................................

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

7. 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. 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