<style type="text/css">
	table.disdukcapil
	{
		font-size: 10pt;
		width: 100%;
		/*border-collapse: collapse;*/
	}
	table.disdukcapil td
	{
		padding: 1px 1px 1px 3px;
	}
	table.disdukcapil td.satu
	{
		width: 10px;
		text-align: center;
	}
	table.disdukcapil td.padat
	{
		padding: 0px;
		margin: 0px;
		font-size: 9.5pt;
	}
	table.disdukcapil td.kotak
	{
		border: solid 1px #000000;
	}
	table.disdukcapil td.kanan { text-align: right; }
	table.disdukcapil td.tengah { text-align: center; }
	table.pengikut
	{
		font-size: 10pt;
		margin-top: 25px;
		border-collapse: collapse;
		border: solid 1px black;
		width:100%;
	}
	table.pengikut td,th
	{
		border: solid 1px black;
		padding: 1px 1px 1px 3px;
	}
	table.pengikut th
	{
		text-align: center;
		vertical-align: middle;
	}
	table.pengikut td.tengah { text-align: center; }
	table.ttd
	{
		margin-top: 20px;
		width: 100%;
	}
	table.ttd td { text-align: center; }
</style>

<page orientation="portrait" format="210x330" style="font-size: 10pt">
	<table align="right" style="padding: 5px 20px; border: solid 1px black;">
		<tr><td><strong><?= $input['kode_format']?></strong></td></tr>
	</table>
	<table style="margin-top: 10px;" class="disdukcapil">
		<col style="width: 26%;">
		<col span="6" style="width: 4%;">
		<col style="width: 50%;">
		<tr>
			<td>PROVINSI</td>
			<td>:</td>
			<?php for ($i=0; $i<2; $i++): ?>
				<td class="kotak tengah">
					<?php if (isset($config['kode_propinsi'][$i])): ?>
						<?= $config['kode_propinsi'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=2>&nbsp;</td>
			<td class="kanan">*)</td>
			<td class="kotak"><?= $config['nama_propinsi'];?></td>
		</tr>
		<tr>
			<td>KABUPATEN/KOTA</td>
			<td>:</td>
			<?php for ($i=0; $i<2; $i++): ?>
				<td class="kotak tengah">
					<?php if (isset($config['kode_kabupaten'][$i])): ?>
						<?= $config['kode_kabupaten'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=2>&nbsp;</td>
			<td class="kanan">*)</td>
			<td class="kotak"><?= $config['nama_kabupaten'];?></td>
		</tr>
		<tr>
			<td>KECAMATAN</td>
			<td>:</td>
			<?php for ($i=0; $i<2; $i++): ?>
				<td class="kotak tengah">
					<?php if (isset($config['kode_kecamatan'][$i])): ?>
						<?= $config['kode_kecamatan'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=2>&nbsp;</td>
			<td class="kanan">*)</td>
			<td class="kotak"><?= $config['nama_kecamatan'];?></td>
		</tr>
		<tr>
			<td>DESA/KELURAHAN</td>
			<td>:</td>
			<?php for ($i=0; $i<4; $i++): ?>
				<td class="kotak tengah">
					<?php if (isset($config['kode_desa'][$i])): ?>
						<?= $config['kode_desa'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td class="kanan">*)</td>
			<td class="kotak"><?= $config['nama_desa'];?></td>
		</tr>
		<tr>
			<td>DUSUN/DUKUH/KAMPUNG</td>
			<td>:</td>
			<td colspan=6 class="kotak"><?= $individu['dusun'];?></td>
		</tr>
	</table>
	<p style="text-align: center;">
			<strong style="font-size: 12pt;">FORMULIR PERMOHONAN PINDAH WNI</strong><br>
			<?= $input['judul_format']?><br>
			No. .................................
	</p>

	<table class="disdukcapil">
		<col style="width: 3%;">
		<col style="width: 24.4%;">
		<col span="22" style="width: 3.3%">
		<tr>
			<td colspan=2><strong>DATA DAERAH ASAL</strong></td>
			<td colspan=22>&nbsp;</td>
		</tr>
		<tr>
			<td>1.</td>
			<td>Nomor Kartu Keluarga</td>
			<?php for ($i=0; $i<16; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($individu['no_kk'][$i])): ?>
						<?= $individu['no_kk'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=6>&nbsp;</td>
		</tr>
		<tr>
			<td>2.</td>
			<td>Nama Kepala Keluarga</td>
			<td colspan=22 class="kotak"><?= $individu['kepala_kk']; ?></td>
		</tr>
		<tr>
			<td>3.</td>
			<td>Alamat</td>
			<td colspan=12 class="kotak"><?= $individu['alamat']; ?></td>
			<td colspan=2 style="text-align: center;">RT</td>
			<?php for ($i=0; $i<3; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($individu['rt'][$i])): ?>
						<?= $individu['rt'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=2 style="text-align: center;">RW</td>
			<?php for ($i=0; $i<3; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($individu['rw'][$i])): ?>
						<?= $individu['rw'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
		</tr>

		<tr>
			<td colspan=2>&nbsp;</td>
			<td colspan=7>Dusun/Dukuh/Kampung</td>
			<td colspan=15 class="kotak"><?= $individu['dusun']; ?></td>
		</tr>

		<tr>
			<td>&nbsp;</td>
			<td>a. Desa/Kelurahan</td>
			<td colspan=8 class="kotak"><?= $config['nama_desa'];?></td>
			<td colspan=4>c. Kab/Kota</td>
			<td colspan=10 class="kotak"><?= $config['nama_kabupaten'];?></td>
		</tr>

		<tr>
			<td>&nbsp;</td>
			<td>b. Kecamatan</td>
			<td colspan=8 class="kotak"><?= $config['nama_kecamatan'];?></td>
			<td colspan=4>d. Provinsi</td>
			<td colspan=10 class="kotak"><?= $config['nama_propinsi'];?></td>
		</tr>

		<tr>
			<td colspan=2>&nbsp;</td>
			<td colspan=3>Kode Pos</td>
			<?php for ($i=0; $i<5; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($config['kode_pos'][$i])): ?>
						<?= $config['kode_pos'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=4>Telepon</td>
			<?php for ($i=0; $i<10; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($input['telepon'][$i])): ?>
						<?= trim($input['telepon'][$i]);?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
		</tr>

		<tr>
			<td>4.</td>
			<td>NIK Pemohon</td>
			<?php for ($i=0; $i<16; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($individu['nik'][$i])): ?>
						<?= $individu['nik'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=6>&nbsp;</td>
		</tr>

		<tr>
			<td>5.</td>
			<td>Nama Lengkap</td>
			<td colspan=22 class="kotak"><?= $individu['nama']; ?></td>
		</tr>
		<tr><td colspan=24>&nbsp;</td></tr>
		<tr>
			<td colspan=2><strong>DATA KEPINDAHAN</strong></td>
			<td colspan=22>&nbsp;</td>
		</tr>

		<tr>
			<td rowspan="2">1.</td>
			<td rowspan="2">Alasan Pindah</td>
			<td rowspan="2" class="kotak satu"><?= trim($input['alasan_pindah_id'],"'"); ?></td>
			<td rowspan="2">&nbsp;</td>
			<td colspan=4 class="padat">1. Pekerjaan</td>
			<td colspan=4 class="padat">3. Keamanan</td>
			<td colspan=4 class="padat">5. Perumahan</td>
			<td colspan=8 class="padat">7. Lainnya (sebutkan)</td>
		</tr>

		<tr>
			<td colspan=4 class="padat">2. Pendidikan</td>
			<td colspan=4 class="padat">4. Kesehatan</td>
			<td colspan=4 class="padat">6. Keluarga</td>
			<td colspan=8 class="padat">
				<?php if ($input['sebut_alasan']): ?>
					<span style='text-decoration: none; border-bottom: 1px dotted black;'><?= $input['sebut_alasan'];?></span>
				<?php else: ?>
					..............................
				<?php endif; ?>
			</td>
		</tr>

		<tr>
			<td>2.</td>
			<td>Alamat Tujuan Pindah</td>
			<td colspan=12 class="kotak"><?= $input['alamat_tujuan']; ?></td>
			<td colspan=2 style="text-align: center;">RT</td>
			<?php for ($i=0; $i<3; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($input['rt_tujuan'][$i])): ?>
						<?= $input['rt_tujuan'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
			<td colspan=2 style="text-align: center;">RW</td>
			<?php for ($i=0; $i<3; $i++): ?>
				<td class="kotak satu">
					<?php if (isset($input['rw_tujuan'][$i])): ?>
						<?= $input['rw_tujuan'][$i];?>
					<?php else: ?>
						&nbsp;
					<?php endif; ?>
				</td>
			<?php endfor; ?>
		</tr>

		<tr>
			<td colspan=2>&nbsp;</td>
			<td colspan=7>Dusun/Dukuh/Kampung</td>
			<td colspan=15 class="kotak"><?= $input['dusun_tujuan']; ?></td>
		</tr>

		<tr>
			<td>&nbsp;</td>
			<td>a. Desa/Kelurahan</td>
			<td colspan=8 class="kotak"><?= $input['desa_tujuan'];?></td>
			<td colspan=4>c. Kab/Kota</td>
			<td colspan=10 class="kotak"><?= $input['kabupaten_tujuan'];?></td>
		</tr>
		<tr>
			<td>&nbsp;</td>
			<td>b. Kecamatan</td>
			<td colspan=8 class="kotak"><?= $input['kecamatan_tujuan'];?></td>
			<td colspan=4>d. Provinsi</td>
			<td colspan=10 class="kotak"><?= $input['provinsi_tujuan'];?></td>
		</tr>
		<tr>
      <td colspan=2>&nbsp;</td>
      <td colspan=3>Kode Pos</td>
      <?php for($i=0; $i<5; $i++): ?>
        <td class="kotak satu">
          <?php if(isset($input['kode_pos_tujuan'][$i])): ?>
            <?= $input['kode_pos_tujuan'][$i]; ?>
					<?php else: ?>
 						&nbsp;
					<?php endif; ?>
        </td>
      <?php endfor; ?>
      <td colspan=4>Telepon</td>
      <?php for($i=0; $i<10; $i++): ?>
        <td class="kotak satu">
          <?php if(isset($input['telepon_tujuan'][$i])): ?>
            <?= trim($input['telepon_tujuan'][$i]); ?>
					<?php else: ?>
					  &nbsp;
					<?php endif; ?>
        </td>
      <?php endfor; ?>
    </tr>

		<tr>
			<td rowspan="2">3.</td>
			<td rowspan="2">Jenis Kepindahan</td>
			<td rowspan="2" class="kotak satu"><?= trim($input['jenis_kepindahan_id'],"'"); ?></td>
			<td colspan=11 class="padat">1. Kep. Keluarga</td>
			<td colspan=10 class="padat">3. Kep. Keluarga dan Sbg. Angg. Keluarga</td>
		</tr>
		<tr>
			<td colspan=11 class="padat">2. Kep. Keluarga dan Seluruh Angg. Keluarga</td>
			<td colspan=10 class="padat">4. Angg. Keluarga</td>
		</tr>

		<tr>
			<td>4.</td>
			<td>Status KK Bagi Yang Tidak Pindah</td>
			<td class="kotak satu"><?= ($input['status_kk_tidak_pindah_id']) ? $input['status_kk_tidak_pindah_id'] : "-"; ?></td>
			<td colspan=5 class="padat">1. Numpang KK</td>
			<td colspan=6 class="padat">2. Membuat KK Baru</td>
			<td colspan=7 class="padat">3. Nomor KK Tetap</td>
		</tr>

		<tr>
			<td>5.</td>
			<td>Status KK Bagi Yang Pindah</td>
			<td class="kotak satu"><?= $input['status_kk_pindah_id']; ?></td>
			<td colspan=5 class="padat">1. Numpang KK</td>
			<td colspan=6 class="padat">2. Membuat KK Baru</td>
			<td colspan=7 class="padat">3. Nomor KK Tetap</td>
		</tr>
		<tr>
			<td>6.</td>
			<td>Keluarga Yang Pindah</td>
			<td colspan=20>&nbsp;</td>
		</tr>
	</table>

	<table class="pengikut">
		<tr>
			<th style="width: 5%">NO.</th>
			<th style="width: 35%" colspan=16>NIK</th>
			<th style="width: 33%">NAMA</th>
			<th style="width: 17%">MASA BERLAKU KTP S/D</th>
			<th style="width: 10%" colspan=2>SHDK</th>
		</tr>

		<?php
			for ($i = 0; $i < MAX_PINDAH; $i++):
				$nomor = $i+1;
				if ($i < count($input['id_cb'])):
					$id = trim($input['id_cb'][$i],"'");
					$penduduk = $this->penduduk_model->get_penduduk($id); ?>

					<tr>
						<td class="tengah"><?= $nomor;?></td>
						<?php for ($j=0; $j<16; $j++): ?>
							<td class="tengah">
								<?php if (isset($penduduk['nik'][$j])): ?>
									<?= $penduduk['nik'][$j];?>
								<?php else: ?>
									&nbsp;
								<?php endif; ?>
							</td>
						<?php endfor; ?>
						<td><?= $penduduk['nama']; ?></td>
						<td>
							<?php if ($input['ktp_berlaku'][$i]): ?>
								<?= $input['ktp_berlaku'][$i];?>
							<?php else: ?>
								&nbsp;
							<?php endif; ?>
						</td>
						<?php $shdk = str_pad($penduduk['kk_level'],2,"0",STR_PAD_LEFT);?>
						<?php for ($j=0; $j<2; $j++): ?>
							<td class="tengah">
								<?= $shdk[$j];?>
							</td>
						<?php endfor; ?>
					</tr>

				<?php else: ?>
					<tr>
						<?php for ($k=0; $k<21; $k++): ?>
							<td>&nbsp;</td>
						<?php endfor; ?>
					</tr>
				<?php endif; ?>
			<?php endfor; ?>

	 </table>

	 <table class="ttd">
		<col style="width:45%">
		<col style="width:10%">
		<col style="width:45%">
		<tr>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
			<td>............................, ........................</td>
		</tr>
		<tr>
			<td>Petugas Registrasi</td>
			<td>&nbsp;</td>
			<td>Pemohon</td>
		</tr>
		<tr style="font-size: 30mm; line-height: normal;">
			<td>&nbsp;</td>
			<td>&nbsp;</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>(...............................................)</td>
			<td>&nbsp;</td>
			<td>(...............................................)</td>
		</tr>
	</table>
	<p>
		<strong>Keterangan:</strong><br>
		*) Diisi Oleh Petugas
	</p>

</page>