Attachment 2 PMA No.

2 of 1990
Article 28 paragraph (4)
Model NA

REPUBLIC OF INDONESIA

EXCERPT OF MARRIAGE CERTIFICATE

OFFICE OF RELIGIOUS AFFAIRS
District : LENGKONG

Regency/Municipal : BANDUNG

Province : WEST JAVA

Husband Wife

Photograph of Photograph of
the bridegroom the
bride
 SERIAL: AA III WIFE
1. Full name and alias : TANTI LISTIANTI.................
Arabic letters denoting:
2. Place and date of birth : GARUT, November 7, 1961
“...and you should not treat your wife with harshness“ (Surah An-Nisa, Verse 19) 3. Citizen of : Indonesia...............................
4. Religion : Muslim...................................
5. Occupation : Employee..............................
EXCERPT OF MARRIAGE CERTIFICATE 6. Address : Jl. Pend. Raya RT 06/ 01..
For the HUSBAND
7. Latest education : .............................................
Number : 315 /37/X/91 8. Pre-marital status : Single...................................
12 Natural parents : Father: Abu Hanifah M. .....
I. Was performed a marriage: 12 R. AKHIR of 1412 H Mother: Siti Rohani............
contract: on the day, date, month, SUNDAY, October 20, 1991 AD
year (hijri & AD) & time IV. WEDDING GUARDIAN

II HUSBAND 1. Status of guardian : Nasab

2. Relationship : Father
1. Full name and alias : ADANG BUNYAMIN........... 3. Full name and alias : Soeffian Affandi
2. Place and date of birth : GARUT, November 7, 1961 4. Son of : Affandi
3. Citizen of : Indonesia............................... 5. Place and date of birth : Purwakarta, Feb 25, 1943
4. Religion : Muslim................................... 6. Citizen of : Indonesia
5. Occupation : Employee.............................. 7. Religion : Muslim
8. Occupation : Civil Servant
6. Address : Jl. Pend. Raya RT 06/ 01..
9. Address : Jl. Pang. Batur Utara 1 BJR
7. Latest education : .............................................
8. Pre-marital status : Single................................... V. DOWRY
12. Natural parents : Father: Abu Hanifah M. .....
Mother: Siti Rohani............ 1. Type of dowry & value : Prayer set + 1 diamond ring
2. Paid in cash or payable : In cash.
VI. MARRIAGE AGREEMENT

1 State any other

agreement : None

VII. RULES ON DIVORCE

(TAKLIK TALAK)

Thereafter the husband

pronounces/reads the
rules on divorce taklik/
talak: (yes/no): Yes

XVII If the marriage

registration is based on
court ruling, state:
Jurisdiction of the court
1. No. and date of ruling
---
2.
---

BANDUNG, October 21, 1991

Certified copy
Office of the Religious Affairs
District of LENGKONG.....
Marriage Registrar *)

(signed by)

LILI ABDUL DJALIL

Reg. No. 150 101 962
*)
Clear name