Contoh Surat Pernyataan menyerahkan Anak

SURAT PERNYATAAN

Kami yang bertanda tangan dibawah ini   :

Nama ayah                   :­­­­­­­­­­­­­­­­­­­­­­­­­­­­­ _______________________________________________

Tempat/tanggal Lahir      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Pekerjaan                      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Alamat                          : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Nama Ibu                      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Tempat/Tanggal Lahir     : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Pekerjaan                      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Alamat                          : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Dengan ini menyatakan Bahwa Anak kami :

Nama                           : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Tempat/Tanggal Lahir     : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Anak ke                        : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Jenis kelamin                : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Dengan ini kami bersungguh-sungguh menyerahkan anak ini  karena ketidak mampuan kami, kepada :

Nama                           : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Umur                            : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Pekerjaan                      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Alamat                          : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Dan

Nama Ibu                      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Tempat/Tanggal Lahir     : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Pekerjaan                      : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Alamat                          : ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________

Demikian surat pernyataan ini kami buat dengan sebenar-benarnya tanpa ada paksaan dari pihak manapun.

Tanjungpinang,  04 agustus 2013

Yang mebuat pernyataan

      Ayah                                                  Ibu

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Saksi – saksi :

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Mengetahui

Ketua RT.