<page orientation="portrait" format="F4" style="font-size: 11pt">

    <!-- Judul Lampiran -->
    <table align="right">
        <tr>
            <td colspan="10">Lampiran IX</td>
        </tr>
        <tr>
            <td colspan="10">Kepdirjen Bimas Islam Nomor 473 Tahun 2020</td>
        </tr>
        <tr>
            <td colspan="10">Tentang</td>
        </tr>
        <tr>
            <td colspan="10">Petunjuk Teknis Pelaksanaan Pencatatan Nikah</td>
        </tr>
        <tr>
            <?php for ($i = 0; $i < 48; $i++) : ?>
                <td>&nbsp;</td>
            <?php endfor; ?>
        </tr>
    </table>

    <!-- Model N4 -->
    <table align="right">
        <tr>
            <td><strong>Model N5</strong></td>
            <td colspan="30">&nbsp;</td>
        </tr>
    </table>

    <br>
    <p class="title-nikah">SURAT IZIN ORANG TUA</p>

    <p>Yang bertanda tangan di bawah ini :</p>

    <table id="kop" class="disdukcapil">
        <col span="48" style="width: 2.0833%;">
        <!-- data ayah -->
        <tr>
            <td colspan="1">A.</td>
            <td colspan="20">1. Nama lengkap dan alias</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma_dapw]</strong></td>
        </tr>
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">2. Bin</td>
            <td>: </td>
            <td colspan="27">[Form_bin_dapW]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">3. Nomor Induk Kependudukan</td>
            <td>: </td>
            <td colspan="27">[NiK_dapw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">4. Tempat dan tanggal lahir</td>
            <td>: </td>
            <td colspan="27">[TtL_dapw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">5. Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WArga_negara_dapw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">6. Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma_dapw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">7. Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan_dapw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">8. Alamat</td>
            <td>: </td>
            <td colspan="27">[Alamat_dapW]</td>
        </tr>

        <!-- data ibu -->
        <tr>
            <td colspan="1">B.</td>
            <td colspan="20">1. Nama lengkap dan alias</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma_dibpw]</strong></td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">2. Binti</td>
            <td>: </td>
            <td colspan="27">[Form_binti_dibpW]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">3. Nomor Induk Kependudukan</td>
            <td>: </td>
            <td colspan="27">[NiK_dibpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">4. Tempat dan tanggal lahir</td>
            <td>: </td>
            <td colspan="27">[TtL_dibpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">5. Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WArga_negara_dibpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">6. Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma_dibpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">7. Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan_dibpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">8. Alamat</td>
            <td>: </td>
            <td colspan="27">[Alamat_dibpW]</td>
        </tr>

        <!-- data individu -->
        <tr>
            <td colspan="48">adalah ayah dan ibu kandung dari :</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">1. Nama lengkap dan alias</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma_dcpw]</strong></td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">2. Binti</td>
            <td>: </td>
            <td colspan="27">[Form_binti_dcpW]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">3. Nomor Induk Kependudukan</td>
            <td>: </td>
            <td colspan="27">[NiK_dcpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">4. Tempat dan tanggal lahir</td>
            <td>: </td>
            <td colspan="27">[TtL_dcpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">5. Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WArga_negara_dcpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">6. Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma_dcpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">7. Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan_dcpw]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">8. Alamat</td>
            <td>: </td>
            <td colspan="27">[Alamat_dcpW]</td>
        </tr>

        <!-- data calon pasangan  -->

    </table>

    <p>Memberikan izin kepada anak kami untuk melakukan pernikahan dengan :</p>
    <table id="kop" class="disdukcapil">
        <col span="48" style="width: 2.0833%;">
        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">1. Nama lengkap dan alias</td>
            <td>: </td>
            <td colspan="27"><strong>[NAma]</strong></td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">2. Bin</td>
            <td>: </td>
            <td colspan="27">[Form_biN]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">3. Nomor Induk Kependudukan</td>
            <td>: </td>
            <td colspan="27">[NiK]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">4. Tempat dan tanggal lahir</td>
            <td>: </td>
            <td colspan="27">[TtL]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">5. Kewarganegaraan</td>
            <td>: </td>
            <td colspan="27">[WArga_negara]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">6. Agama</td>
            <td>: </td>
            <td colspan="27">[AgAma]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">7. Pekerjaan</td>
            <td>: </td>
            <td colspan="27">[PeKerjaan]</td>
        </tr>

        <tr>
            <td colspan="1">&nbsp;</td>
            <td colspan="20">8. Alamat</td>
            <td>: </td>
            <td colspan="27">[AlamaT]</td>
        </tr>

    </table>


    <p style="text-align: justify; text-indent: 30px;">Demikian surat izin ini dibuat dengan kesadaran tanpa ada paksaan dari siapapun dan untuk digunakan seperlunya.</p>


    <!-- Penandatangan -->
    <br><br><br>
    <table style="border-collapse: collapse; width: 100%; height: 144px;" border="0">
    <tbody>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;"> </td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;">[Nama_desA], [TgL_surat]</td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;">Ayah/wali/pengampu</td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;">Ibu/wali/pengampu</td>
    </tr>
    <tr style="height: 72px;">
    <td style="width: 26.6281%; text-align: center; height: 72px;"> </td>
    <td style="width: 2.75528%; height: 72px;"><br><br><br><br></td>
    <td style="width: 70.6166%; height: 72px;"> </td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;"><strong>[NAma_dapw]</strong></td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;"><strong>[NAma_dibpw]</strong></td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; height: 18px;"> </td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;"> </td>
    </tr>
    <tr style="height: 18px;">
    <td style="width: 26.6281%; text-align: center; height: 18px;">[qr_code]</td>
    <td style="width: 2.75528%; height: 18px;"> </td>
    <td style="width: 70.6166%; text-align: center; height: 18px;"> </td>
    </tr>
    </tbody>
    </table>
</page>