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<page orientation="portrait" format="210x330" style="font-size: 8pt">
	<table align="right" style="padding: 5px 20px; border: solid 1px black;">
		<tr><td><strong style="font-size: 14pt;">F-1.15</strong></td></tr>
	</table>
	<p style="text-align: center; margin-top: 40px;">
			<strong style="font-size: 12pt;">FORMULIR PERMOHOHAN KARTU KELUARGA (KK) BARU WARGA NEGARA INDONESIA</strong>
	</p>
	<table class="disdukcapil" style="margin-top: 0px;">
		<col span="48" style="width: 2.0833%;">
		<tr>
			<td class="kotak" colspan=48>
				<strong>Perhatian:</strong><br>
				1. Harap diisi dengan huruf cetak dan menggunakan tinta hitam<br>
				2. Setelah formulir ini diisi dan ditandatangani, harap diserahkan kembali ke Kantor Desa/Kelurahan
			</td>
		</tr>
		<tr>
			<td colspan="13" class="left"><strong>PEMERINTAH PROPINSI</strong></td>
			<td>:</td>
			<?php for ($i=0; $i<2; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($config['kode_propinsi'][$i])): ?>
						<?= $config['kode_propinsi'][$i]; ?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=3>&nbsp;</td>
			<td colspan="17" class="kotak"><?= $config['nama_propinsi'];?></td>
			<td colspan=12>&nbsp;</td>
		</tr>

		<tr>
			<td colspan="13" class="left"><strong>PEMERINTAH KABUPATEN/KOTA</strong></td>
			<td>:</td>
			<?php for ($i=0; $i<2; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($config['kode_kabupaten'][$i])): ?>
						<?= substr($config['kode_kabupaten'], 2, 4)[$i]; ?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=3>&nbsp;</td>
			<td colspan="17" class="kotak"><?= $config['nama_kabupaten'];?></td>
			<td colspan=12>&nbsp;</td>
		</tr>

		 <tr>
			<td colspan="13" class=" left"><strong>KECAMATAN</strong></td>
			<td>:</td>
			<?php for ($i=0; $i<2; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($config['kode_kecamatan'][$i])): ?>
						<?= substr($config['kode_kecamatan'], 4, 6)[$i]; ?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=3>&nbsp;</td>
			<td colspan="17" class="kotak"><?= $config['nama_kecamatan'];?></td>
			<td colspan=12>&nbsp;</td>
		</tr>

		<tr>
			<td colspan="13" class="left"><strong>KELURAHAN/DESA</strong></td>
			<td>:</td>
			<?php for ($i=0; $i<4; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($config['kode_desa'][$i])): ?>
						<?= substr($config['kode_desa'], 6, 10)[$i]; ?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td>&nbsp;</td>
			<td colspan="17" class="kotak"><?= $config['nama_desa'];?></td>
			<td colspan=12>&nbsp;</td>
		</tr>
		<tr><td colspan=48 class="bawah">&nbsp;</td></tr>
		<tr><td colspan=48>&nbsp;</td></tr>

		<tr>
			<td colspan="10" class="kotak">1. Nama Lengkap Pemohon</td>
			<td>:</td>
			<?php for ($i=0; $i<33; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($individu['nama'][$i])): ?>
						<?= $individu['nama'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan="4">&nbsp;</td>
		</tr>
		<tr>
			<td colspan="10" class="kotak">2. NIK Pemohon</td>
			<td>:</td>
			<?php for ($i=0; $i<16; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($individu['nik'][$i])): ?>
						<?= $individu['nik'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=21>&nbsp;</td>
		</tr>
		<tr>
			<td colspan=10 class="kotak">3. No. KK Semula</td>
			<td>:</td>
			<?php for ($i=0; $i<16; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($input['no_kk_semula'][$i])): ?>
						<?= $input['no_kk_semula'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=21 class="left">*) Diisi oleh petugas</td>
		</tr>
		<tr>
			<td colspan="10" class="kotak">4. Alamat Pemohon</td>
			<td>:</td>
			<td colspan="23" class="kotak"><?= $individu['alamat']?></td>
			<td colspan="3" class="tengah">RT:</td>
			<?php for ($i=0; $i<3; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($individu['rt'][$i])): ?>
						<?= $individu['rt'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan="3" class="tengah">RW:</td>
			<?php for ($i=0; $i<3; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($individu['rw'][$i])): ?>
						<?= $individu['rw'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan="2">&nbsp;</td>
		</tr>
		<tr>
			<td colspan="11" >&nbsp;</td>
			<td colspan="7" class="left">a. Desa/Kelurahan</td>
			<td colspan="12" class="kotak"><?= $config['nama_desa'];?></td>
			<td colspan="5" class="left">b. Kecamatan</td>
			<td colspan="12" class="kotak"><?= $config['nama_kecamatan'];?></td>
			<td colspan="1">&nbsp;</td>
		</tr>
		<tr>
			<td colspan="11" >&nbsp;</td>
			<td colspan="7" class="left">c. Kabupaten/Kota</td>
			<td colspan="12" class="kotak"><?= $config['nama_kabupaten'];?></td>
			<td colspan="5" class="left">d. Propinsi</td>
			<td colspan="12" class="kotak"><?= $config['nama_propinsi'];?></td>
			<td colspan="1">&nbsp;</td>
		</tr>
		<tr>
			<td colspan="11">&nbsp;</td>
			<td colspan="7" class="left">Kode Pos</td>
			<?php for ($i=0; $i<5; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($config['kode_pos'][$i])): ?>
						<?= $config['kode_pos'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan="7">&nbsp;</td>
			<td colspan="5" class="left">Telepon</td>
			<?php for ($i=0; $i<8; $i++): ?>
				<td class="kotak padat tengah">
					<?php if (isset($individu['telepon_kk'][$i])): ?>
						<?= $individu['telepon_kk'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan="5">&nbsp;</td>
		</tr>
		<tr>
			<td colspan="10" class="kotak">5. Alasan Permohonan</td>
			<td>:</td>
			<td class="kotak"><?= $input['alasan_permohonan_id']?></td>
			<td>&nbsp;</td>
			<td colspan="16" class="left">1. Karena Membentuk Rumah Tangga Baru</td>
			<td colspan="19" class="left">3. Lainnya</td>
		</tr>
		<tr>
			<td colspan="13" >&nbsp;</td>
			<td colspan="35" class="left">2. Karena Kartu Keluarga Hilang/Rusak</td>
		</tr>
		<tr>
			<td colspan="10" class="kotak">6. Jumlah Anggota Keluarga</td>
			<td>&nbsp;</td>
			<?php $str_jml = str_pad((string)count($anggota_ikut),2,"0",STR_PAD_LEFT); ?>
			<?php for ($j=0; $j<2; $j++): ?>
				<td class="kotak padat tengah"><?= $str_jml[$j];?></td>
			<?php endfor; ?>
			<td colspan="2" style="text-align: right" >orang</td>
			<td colspan="33">&nbsp;</td>
		</tr>
		<tr><td colspan="48" class="atas">&nbsp;</td></tr>

		<tr>
			<td colspan="48">
				7. <strong>DAFTAR ANGGOTA KELUARGA PEMOHON (hanya diisi anggota keluarga saja)</strong>
			</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td colspan="2" class="abu">No.</td>
			<td>&nbsp;</td>
			<td colspan="16" class="abu">NIK</td>
			<td>&nbsp;</td>
			<td colspan="22" class="abu">Nama Lengkap</td>
			<td>&nbsp;</td>
			<td colspan="3" class="abu">SHDK*)</td>
			<td>&nbsp;</td>
		</tr>
		<?php for ($i=0; $i<MAX_ANGGOTA_F115; $i++): ?>
			<tr>
				<td>&nbsp;</td>
				<?php $str_i = str_pad((string)($i+1),2,"0",STR_PAD_LEFT); ?>
				<?php for ($j=0; $j<2; $j++): ?>
					<td class="kotak padat tengah"><?= $str_i[$j];?></td>
				<?php endfor; ?>
				<td>&nbsp;</td>
				<?php if ($i < count($anggota_ikut)): ?>
					<?php for ($j=0; $j<16; $j++): ?>
						<td class="kotak padat tengah">
							<?php if (isset($anggota_ikut[$i]['nik'][$j])): ?>
								<?=$anggota_ikut[$i]['nik'][$j];?>
							<?php else: ?>
								&nbsp;
							<?php endif; ?>
						</td>
					<?php endfor; ?>
					<td>&nbsp;</td>
					<td colspan="22" class="tengah kotak"><?= $anggota_ikut[$i]['nama']?></td>
					<td>&nbsp;</td>
					<?php for ($j=0; $j<2; $j++): ?>
						<?php $str_kk_level = str_pad($anggota_ikut[$i]['kk_level'],2,"0",STR_PAD_LEFT); ?>
						<td class="kotak padat tengah"><?= $str_kk_level[$j];?></td>
					<?php endfor; ?>
					<td colspan="2">&nbsp;</td>
				<?php else: ?>
					<?php for ($j=0; $j<16; $j++): ?>
						<td class="kotak padat tengah">&nbsp;</td>
					<?php endfor; ?>
					<td>&nbsp;</td>
					<td colspan="22" class="tengah kotak">&nbsp;</td>
					<td>&nbsp;</td>
					<?php for ($j=0; $j<2; $j++): ?>
						<td class="kotak padat tengah">&nbsp;</td>
					<?php endfor; ?>
					<td colspan="2">&nbsp;</td>
				<?php endif; ?>
			</tr>
		<?php endfor; ?>
		<tr><td>&nbsp;</td></tr>
		<tr>
			<td colspan="46" style="text-align: right">
				<?= str_pad(".",40,".",STR_PAD_LEFT);?>,<?= str_pad(".",60,".",STR_PAD_LEFT);?>
			</td>
			<td colspan="2">&nbsp;</td>
		</tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr>
			<td colspan="4">&nbsp;</td>
			<td colspan="16" style="text-align: center;">Mengetahui</td>
			<td colspan="15">&nbsp;</td>
			<td colspan="12" style="text-align: center;">Pemohon</td>
			<td>&nbsp;</td>
		</tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr>
			<td>&nbsp;</td>
			<td colspan="11" style="text-align: center;">Camat</td>
			<td>&nbsp;</td>
			<td colspan="13" style="text-align: center;"><?= $this->penandatangan_lampiran($data);?></td>
			<td colspan="22">&nbsp;</td>
		</tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr>
			<td>&nbsp;</td>
			<td colspan="11"><?= str_pad(".",50,".",STR_PAD_LEFT);?></td>
			<td>&nbsp;</td>
			<td colspan="13" style="text-align: center;"><strong>(<?= padded_string_center(strtoupper($kepala_desa['pamong_nama']),30)?>)</strong></td>
			<td colspan="9">&nbsp;</td>
			<td colspan="12" style="text-align: center;"><strong>(<?= padded_string_center(strtoupper($individu['nama']),30)?>)</strong></td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td colspan="11" style="text-align: center;"><?= "NIP&nbsp;&nbsp;:&nbsp;".str_pad("",40*6,"&nbsp;",STR_PAD_LEFT)?></td>
			<td>&nbsp;</td>
			<td colspan="13" style="text-align: center;"><?= "NIP&nbsp;&nbsp;:&nbsp;".$kepala_desa['pamong_nip']?></td>
			<td colspan="22">&nbsp;</td>
		</tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr>
			<td colspan="26">&nbsp;</td>
			<td colspan="22"><strong>Tanggal Pemasukan Data</strong></td>
		</tr>
		<tr>
			<td colspan="26">&nbsp;</td>
			<td colspan="2" style="text-align: left;">Tgl.</td>
			<?php for ($j=0; $j<2; $j++): ?>
				<td class="kotak padat tengah">&nbsp;</td>
			<?php endfor; ?>
			<td colspan="2" style="text-align: center;">Bln.</td>
			<?php for ($j=0; $j<2; $j++): ?>
				<td class="kotak padat tengah">&nbsp;</td>
			<?php endfor; ?>
			<td colspan="2" style="text-align: center;">Thn.</td>
			<?php for ($j=0; $j<2; $j++): ?>
				<td class="kotak padat tengah">&nbsp;</td>
			<?php endfor; ?>
			<td colspan="12">&nbsp;</td>
		</tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr>
			<td colspan="26">&nbsp;</td>
			<td colspan="6" style="text-align: left;"><strong>Paraf Petugas</strong></td>
			<td colspan="6" class="kotak">&nbsp;</td>
			<td colspan="10">&nbsp;</td>
		</tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr><td colspan="48">&nbsp;</td></tr>
		<tr>
			<?php for ($i=0; $i<48; $i++): ?>
				<td>&nbsp;</td>
			<?php endfor; ?>
		</tr>
	</table>
</page>
