SURAT AHLI WARIS
Saya yang bertandatangan di bawah ini :
Nama : .....................................................................................................................
N.I.K : .......................................................................................................................
Alamat : .....................................................................................................................
Desa : .....................................................................................................................
Kecamatan : .....................................................................................................................
Kabupaten : .....................................................................................................................
No Telp : .....................................................................................................................
PT : .....................................................................................................................
NEGARA TUJUAN : .....................................................................................................................
Menyatakan bahwa selama menjadi tenaga kerja diluar negeri, bilamana terjadi kecelakaan atau
kematian maka saya melimpahkan / mewariskan kepada :
Nama : .....................................................................................................................
N.I.K : .....................................................................................................................
Tempat / Tanggal Lahir : .....................................................................................................................
Jenis Kelamin : .....................................................................................................................
Alamat : .....................................................................................................................
Desa / Kelurahan : .....................................................................................................................
Kecamatan :......................................................................................................................
Kabupaten / Kota : .....................................................................................................................
Demikian surat pernyataan Ahli Waris ini saya buat dengan sebenarnya tanpa ada paksaan dari pihak lain dan
dapat dipergunakan sebaimana mestinya
Mengetahui ..................., .........................20.....
Kepala Desa/Kelurahan.................. Yang Memberi Kuasa Yang Diberi Kuasa
Materai
10.000
( ) ( ) ( )