K 51080381665

[State Emblem]

FAMILY CARD
Nu mber: 51 0806250811 oo3o

Name of Family Head DEWA KOMANG"SUNITA Sub{istrict BULELENG

Address JL SETIABUDI GG KRESNA LINK. SATRIA Regency/City BULELENG

RT/RW 0041- Postcode 81 151

Village PENARUKAN Province BALI

No. FullName National Sex PIace of Date of Religion Education Occupation

ldentification Birth Birth
Number
(1 )_ (2) (3) (4) (5) {6) 0) (8)
1 DEWA KOI\4ANG 5'l 08062802760007 MALE PENARUKAN 28-02-1975 HINDU NOT AN IMPERMANENT
SUNITA ELETMENTARY LABOUR
SCHOOL/
EQUIVALENT
2 DESAK KOI\4ANG 510806ffi03n0004 FEMALE PANJI 23-03-1973 HINDU SENIOR HIGH IMPERMANENT
SARIATI
SCHOOL/ LABOUR

EQUIVALENT
2 DEWA PUTU 51 0806251 1 970004
MALE PENARUKAN 21-11-1997 HINDU SENIOR HIGH STUDENTS
AGUS SCHOOL/
INDRAWAN EQUIVALENT
4 DESAK KADEK 5 1 080648050200'l 'l
FEMALE PENARUKAN 08-05-2002 HINDU SENIOR HIGH
STUDENTS
TMERY SCHOOL/
SUKI\4AWATI EQUIVALENT

DESAK KOTVANG 51 0806701 01 00006 FEMALE PENARUKAN 30-10-2010 HINDU NOT STARTED UNEMPLOYED
5 I

OKTAVIANI
SCHOOL YEI

I
o
 Relationship lmmigration Document
No. Marital Status in the Cilianship Name of Parents
Status Family Passport Temporary /
Number Permanent
Stay Permit Father Mother
Number
{e) (10) (1 1) fi21 {13) (14) (15)
1 MARRIED FAMILY INDONESIAN DEWAPUTU LABA
HEAD
,l
MARRIED WIFE INDONESIAN DEWAPUTU IVERTA

? SINGLE CHILD INDONESIAN DEWAKOIMANG SUNITA

4 SINGLE CHILD INDONESIAN DEWA KOMANG SUNITA

5 SINGLE CHILD INDONESIAN DEWAKOMANG SUNITA

10

Date of lssue : 10 JULY 2014

HEAD OF DEPARTMENT FOR DEMOGRAPHY
SHEET t. Family Head AND CIVIL REGISTRY OFFICE
il. RT FAMILY HEAD

ilt. Village

IV Sub-district [Signed] [Signed, stamped]

DEWA KOMANG SUNITA IDA BAGUS SUADNYANA. SH. M.Si
Signatureffhumb-print OFFICIAL IDENTIFICATION NUMBER:
196211 1 1 1989031028

Saya FATCHTIROZAI( Penerjemah Tersurnpah di Republik Indonesia I, FATCHLROZAK, a Sworn Translator in the
berdasarkan peraturirn perundang-undangan yang berlaku di Republik Indonesia, Republic of Indonesia by virtue of the applicable laws
dengan ini menerangkan dan menyatakan, sesuai dengan sumpah jabatan saya, and regulations in the Republic of lndonesi4 hereby
tJahwa dokumen ini merupalian terjemahan yang benar, setia" dan lengkap dari state and declare, under my oath of office, that the
dokumen sumber yang diberikan kepada saya. ioregoing document is a true, faithfirl and correct
8 Mzret2024
Jakart4 of the source document in
FATCHUROZAK to me.
Penefemah Tersumpah [Bahasa incionesia ke Bahasa inggris dan Bahasa ?
ke Babasa Indonesia]
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