N O . K PP N . S I M A T I :

A KU AN O L EH AN A K B AG I F A E D A H O R AN G T A N G G U N G AN / PE N C E N P EN AK AT

( P e r a t u r a n 1 1 7 )

Saya

No. Kad Pengenal an mengaku baha wa sa ya: -

CATATAN:

Dalam hal seorang remaja, penjaganya hendaklah menandatangani akuan bagi pihak

remaja itu dan perkataan-perkataan berikut hendaklah dimasukkan.

Saya (nama penj aga ) No. Kad Pengena lan

lama

baru

b a g i p i h a k ( n a m a r e m a j a )

n o k p p n

L a m a ( j i k a a d a ) B a r u ( j i k a a d a )

( p e r t a l i a n n y a ) a d a l a h d e n g a n i n i m e n g a k u b a h a w a b e l i a u : -

(a ) ada l ah s eo rang anak k epada s im at i d a n be r h ak me n d a p a t Fa ed a h Or a ng Ta n gg u n g a n / P enc e n P e n a ka t ; ( N am a S i mat i )

( b ) be l u m m e nc a p a i um u r dua p u l u h s a tu t a hu n d a n b e l um b erk a h wi n ;

( c ) t e l a h b e r k a h w i n p a d a

( d ) t e l a h m e n c a p a i u m u r d u a p u l u h s a t u t a h u n t e t a p i o l e h k e r a n a t e r e n c a t m e n t a l / m e n j a d i t a k u p a y a s e c a r a f i z i k a l , a d a l a h t i d a k b e r u p a y a m e n a n g g u n g d i r i s e n d i r i ;

( e ) t e l a h m e n c a p a i u m u r d u a p u l u h s a t u t a h u n d a n m a s i h m e n e r i m a p e l a j a r a n d i s u a t u i n s t i t u s i p e l a j a r a n t i n g g i i a i t u :

( s i l a s e r t a k a n S i j i l P e r k a h w i n a n y a n g d i a k u i s a h . ) ;

( N a m a I n s t i t u s i P e l a j a r a n T i n g g i )

( S e r t a k a n s u r a t p e n g e s a h a n I n s t i t u s i / L e n g k a p k a n L a m p i r a n A y a n g b o l e h

d i p e r o l e h i d i P e j a b a t P E R K E S O b e r h a m p i r a n )

T a r i k h

A l a m a t p i h a k m e n u n t u t s e k a r a n g : T a n d a t a n g a n a t a u c a p i b u j a r i k a n a n p i h a k o r a n g t a n g g u n g a n / p e n j a g a d i b u a t d i h a d a p a n :

N a m a , t a n d a t a n g a n , j a w a t a n d a n a l a m a t p e j a b a t p i h a k b e r k u a s a y a n g m e n g a k u s a k s i k a n

( Pertukaran alamat hendaklah diberitahu melalui KAD PERTUKARAN

ALAMAT yang terdapat dalam buku waran).

C o p a t a u m e t e r i p i h ak b e r k u a s a ya n g m e n g a k u sa k s i k a n

A k u a n i n i h e n d a k l a h d i t a n d a t a n g a n i d i h a d a p a n s e o r a n g M a j i s t r e t , a t a u J a k s a P e n d a m a i , a t a u P e s u r u h j a y a A k t a P a m p a s a n P e k e r j a 1 9 5 2 , a t a u A k a u n t a n B e r k a n u n , A k a u n t a n B e r t a u l i a h a t a u A k a u n t a n B e r d a f t a r , a t a u N o t a r i A w a m , a t a u P e s u r u h j a y a S u m p a h , a t a u P e g a w a i K e r a j a a n K u m p u l a n A a t a u B , a t a u P e n g h u l u , a t a u K a d i a t a u I m a m a t a u P a d e r i a t a u P e n g g a w a a t a u K e t u a B a l a i P o l i s a t a u G u r u B e s a r a t a u m a n a - m a n a o r a n g l a i n y a n g d i l u l u s k a n o l e h K e t u a E k s e k u t i f P E R K E S O .

FA

NA

K

Sila potong mana-mana yang tidak

berkenaan.

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i) Nama suami / isteri ii) No. KPPN suami / isteri : Lama

Baru

( f ) M e m a h a m i b a h a w a F a e d a h O r a n g T a n g g u n g a n / P e n c e n P e n a k a t y a n g d i b a y a r k e p a d a s a y a / b e l i a u a k a n t e r h e n t i a p a b i l a s a y a / b e l i a u b e r k a h w i n s e b e l u m m e n c a p a i u m u r d u a p u l u h s a t u t a h u n / b e r u p a y a m e n a n g g u n g d i r i s e n d i r i / b e r h e n t i m e n e r i m a p e l a j a r a n d i s u a t u i n s t i t u s i p e l a j a r a n t i n g g i ; d a n ( g ) S e d a r b a h a w a a d a l a h m e n j a d i t a n g g u n g j a w a p s a y a u n t u k m e m b e r i t a h u P e r t u b u h a n

K e s e l a m a t a n S o s i a l a p a b i l a s a y a / b e l i a u b e r k a h w i n s e b e l u m m e n c a p a i u m u r d u a p u l u h s a t u t a h u n / b e r u p a y a m e n a n g g u n g d i r i s e n d i r i / b e r h e n t i m e n e r i m a p e l a j a r a n d i s u a t u i n s t i t u s i p e l a j a r a n t i n g g i d a n s e t e r u s n y a t i d a k b e r h a k m e n e r i m a b a y a r a n F a e d a h O r a n g T a n g g u n g a n / P e n c e n P e n a k a t i t u .

[ N o t a : J i k a i ) A n a k i n i t e l a h m e n i n g g a l d u n i a s i l a s e r t a k a n S i j i l K e m a t i a n . i i ) A t a u a n a k t i d a k t i n g g a l b e r s a m a a t a u d i j a g a o l e h o r a n g l a i n s i l a m a k l u m k a n d e n g a n k e m u k a k a n b o r a n g i n i b e r s a m a - s a m a m a k l u m a t p e n j a g a ]

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N o t e l u n t u k d i h u b u n g i :