FORM

1771
MINISTRY OF FINANCE DIRECTORATE GENERAL OF TAXES

CORPORATE ANNUAL INCOME TAX RETURN

ATTENTION h FOLLOW INSTRUCTION IN THE MANUAL h PRINT OR TYPE WITH CAPITAL LETTER OR BLACK INK h MARK "X" IN THE APPROPRIATE BOX

TAXABLE YEAR

2 0 0 9
AMENDED RETURN

TIN

: : : : : KLU :

IDENTITY

TAXPAYER'S NAME BUSINESS CLASIFICATION TELEPHONE NUMBER ACCOUNTING PERIOD

to

FACSIMILE NO.

FOREIGN DOMICILE OF HEAD OFFICE (Permanent Establisment only)

:
AUDIT OPINION UNAUDITED

FINANCIAL STATEMENT NAME OF PUBLIC ACCOUNTANT FIRM TIN OF PUBLIC ACCOUNTANT FIRM NAME OF CPA TIN OF CPA NAME OF TAX CONSULTANT FIRM TIN OF TAX CONSULTANT FIRM NAME OF TAX CONSULTANT TIN OF TAX CONSULTANT

: : : : : : :

AUDITED

: :
IDR *)
(3) 1 (2)

*) The filling of coloumns of Rupiahs must be without decimal value (see example in the manual book page.3)

(1) A. TAXABLE INCOME

1. 2.

FISCAL NET INCOME (Copy from Form 1771-1 line 8 column 3).. FISCAL LOSS CARRIED FORWARD (Copy from Special Attachment 2A Total of Column B) .. TAXABLE INCOME (1 - 2)

2 3

3. 4.

INCOME TAX DUE (Choose one of these Rates according to Taxpayer criteria. See manual book) a. b. c.

B. INCOME TAX DUE

Tax Rate Article 17 paragraph (1) letter b X line 3) Tax Rate Article 17 paragraph (2b) X line 3. Tax Rate Article 31E paragraph (1)
5 4

5.

ADJUSTMENT FOR FOREIGN TAX CREDIT REFUNDED THAT HAD BEEN CREDITED IN THE PREVIOUS YEAR'S RETURN (Income Tax Art.24) TOTAL TAX DUE (4 + 5) INCOME TAX BORNE BY THE GOVERNMENT (Foreign Aid Project) a. b. DOMESTIC TAX CREDIT (Copy from Form 1771-III Total of Column 5) FOREIGN TAX CREDIT (Copy from Special Attachment 7A Total of column 7)

6. 7. 8.

7 8a 8b

C. TAX CREDITS

c. 9. a. b.

TOTAL (8a + 8b) .8c TAX DUE AFTER CREDIT TAX OVERLY WITHHELD (6 - 7 - 8c)
9

10. PREPAID TAX : 10a a. MONTHLY INSTALLMENT TAX ARTICLE 25 b. c. d. NOTICE OF TAX COLLECTION (Principal only)
10b 10c

TAX ARTICLE POINT 8 / DEPARTURE TAX . TOTAL (10a + 10b + 10c) .. UNDERPAID TAX (INCOME TAX ARTICLE 29) OVERPAID TAX (INCOME TAX ARTICLE 28A)
10d

D. INCOME TAX UNDER/OVER PAID

11.

a. b.

(9 - 10d)

11

12.

UNDERPAID TAX ON NUMBER 11.a SETTLED ON

D. INCOME TAX UNDER/OV PAID

TGL

BLN

THN

13.

OVERPAID AMOUNT STATED IN 11.b WOULD BE : a. REFUNDED b. COMPENSATED WITH OUTSTANDING TAX PAYABLE Preliminary Refund (Tax Law on Article 17C or 17D)

Refund for a Taxpayer with Certain Criteria only :

F.1.1.32.14

F.FINAL TAX AND NONE. MONTHLY INSTALLMENT OF ART.25 FOR CURRENT YEAR TAXABLE INCOME

FORM 1771
IDR
(2) (3) 14a 14b (1)

Page 2

14.

a. b.

INCOME BASE FOR CALCULATION OF MONTHLY TAX INSTALLMENT .. FISCALL LOSS CARRIED FORWARD : (From Special Attachment 2A Total of Column 9) TAXABLE INCOME (14a - 14b)

c. d.

14c

TAX DUE 14d (Tax Rate from Part B line 4 X 14c) .. WITHOLDING TAX PAID BASED ON NUMBER 14a

e.

14e 14f 14g

f. g. 15. a.

INCOME TAX MUST BE PAID (14d - 14e) .

INCOME TAX ARTICLE 25 : (1/12 x 14f) . FINAL TAX : (From Form 1771-IV Total Part A Column 5)

15a

b.

NON-TAXABLE INCOME : GROSS INCOME 15b (From Form 1771-IV Total Part B of Column 3) .

G. STATEMENT OF TRANSACTION IN RELATED PARTIES

16.

a.

There is a Transaction in Related Parties and/or with Tax Haven Country Resident (Compulsory to submit Special Attachment 3A, 3A-1. and 3A-2 Manual Book of Annual Return)* There is not a Transaction in Related Parties and/or with Tax Heaven Country Resident.

b.

17.

OTHER THAN FORM OF 1771-I, 1771-II, 1771-III, 1771-IV, 1771-V, AND 1771-VI WITH THIS ALSO ATTACHED : a. b. c. d. THIRD COPY OF TAX PAYMENT RECEIPT OF INCOME TAX ARTICLE 29 FINANCIAL STATEMENTS TRANSCRIPT OF ELEMENTS FROM FINANCIAL STATEMENT (Special Attachment 8A-1 /8A-2 /8A-3 /8A-4 /8A-5 /8A-6)* DEPRECIATION AND AMORTIZATION TABLES (Special Attachment 1A of the Annual Income Tax Return Manual)* CALCULATION OF FISCAL LOSS CARRIED FORWARD (Special Attachment 2A of Income Tax Return Manual)* INVESTMENT FACILITIES PROVIDED (Special Attachment 4A of the Income Tax Return Manual) LIST OF MAJOR BRANCHES (Special Attachment 5A of the Income Tax Return Manual) THIRD COPY OF PAYMENT RECEIPT OF INCOME TAX ARTICLE 26 PARAGRAPH (4) (For Permanent Establishment only) CALCULATION OF INCOME TAX ART.26 PARAGRAPH (4) (Permanent Establishment only) (Special Attachment 6A of Income Tax Return Manual)* FOREIGN TAX CREDITS (Special Attachment 7A Income Tax Return Manual)* POWER OF ATTORNEY (if needed)

H. ATTACHMENTS

e. f. g. h. i. j. k. l. m. n.

.. DECLARATION

Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Wharsoever. a. TAX PAYER b. AUTHORIZED REPRESENTATIVE c.
(place)

d.
date month year

SIGNATURE AND COMPANY SEAL

FULL NAME MANAGEMENT/ REPRESENTATI VE TIN

F.1.1.32.14

e.

f.

FORM

1771 - I
MINISTRY OF FINANCE DIRECTORATE GENERAL OF TAXES TIN TAXPAYER'S NAME ACCOUNTING PERIOD

TAXABLE YEAR

ATTACHMENT-I
CORPORATE ANNUAL INCOME TAX RETURN
CALCULATION OF FISCAL NET INCOME

2 0

: : :
DESCRIPTIONS
(2)

IDENTITY

to

NO
(1)

IDR
(3)

1.

DOMESTIC COMMERCIAL NET INCOME : a. b. c. d. e. f. g. h. GROSS INCOME . . COST OF GOOD SOLD . OTHER EXPENSE .. . NET INCOME FROM BUSINESS (1a - 1b - 1c) .. . INCOME FROM SIDE BUSINESS . EXPENSE FROM SIDE BUSINESS . . NET INCOME FROM SIDE BUSINESS (1e - 1f) . TOTAL (1d + 1g) .. .
2 3 1h 1g 1f 1e 1d 1c 1b 1a

2.

FOREIGN COMMERCIAL NET INCOME (From Special Attachment 7A Column 4).. . TOTAL OF COMMERCIAL NET INCOME (1h + 2) . INCOME SUBJECT TO FINAL TAX AND NON-TAXABLE INCOME.. . POSITIVE FISCAL ADJUSTMENT :

3. 4.

5.

a. EXPENSE CHARGED OR INCURRED FOR THE PERSONAL BENEFIT OF 5a SHAREHOLDERS, PARTNERSHIP OR MEMBERS... .. . b. FORMATION OR ACCUMULATION OF ALLOWANCES .. . c. CONSIDERATION OR REMUNERATION RELATED TO EMPLOYMENT OR 5c SERVICES GIVEN IN THE FORM OF A BENEFIT IN KIND.. .
5b

d. EXCESSIVE COMPENSATION PAID TO SHAREHOLDERS OR OTHER 5d ASSOCIATED PARTIES AS A CONSIDERATION OF WORK PERFOMED. . e. GIFTS, AIDS, OR DONATION

5e 5f

f. INCOME TAX . g. SALARIES PAID TO A MEMBER OF AN ASSOCIATION, FIRMA, OR LIMITED 5g PARTNERSHIP WHICH CAPTAL DOES NOT CONSIST OF STOCKS. . h. ADMINISTRATION SANCTION . . i. j. LESS COMMERCIAL DEPRECIATION OVER FISCAL DEPRECIATION .. . LESS COMMERCIAL AMORTIZATION OVER FISCAL AMORTIZATION .. .
5k 5l 5j 5i 5h

k. DEFERRED EXPENSES .. . l.

OTHER POSITIVE FISCAL ADJUSTMENTS .. .

5m

m. TOTAL 5a s.d. 5l . 6. NEGATIVE FISCAL ADJUSTMENT : a. LESS COMMERCIAL DEPRECIATION UNDER FISCAL DEPRECIATION . .
6b 6c 6a

b. ESS COMMERCIAL AMORTIZATION UNDER FISCAL AMORTIZATION .. . c. DEFERRED INCOME .. .

d. OTHER NEGATIVE FISCAL ADJUSTMENTS .. . e. 7. TOTAL 6a s.d. 6d .

6e

6d

FACILITIES OF INVESTMENT ALLOWANCES YEAR

7a

(From Special Attachment 4A line 5b) .. .

7b

8.

FISCAL NET INCOME (3 - 4 + 5m - 6e - 7b) . .

NOTES : Copy Total of Line 8 to Form 1771 Letter A Line 1.

D.1.1.32.31

FORM

1771 - II
MINISTRY OF FINANCE DIRECTORATE GENERAL OF TAXES TIN ACCOUNTING PERIOD

CORPORATE ANNUAL INCOME TAX RETURN

DETAILS OF COST OF GOOD SOLD, OTHER OPERATING EXPENSE AND COMMERCIAL NON-OPERATING EXPENSE
TAXPAYER'S NAME s.d. :

IDENTITY

: :

NO
(1)

DETAILS
(2)

COST OF GOOD SOLD (IDR)

(3)

OTHER OPERATING EXPENSE (IDR)

(4)

NON-OPERATING EXPENSE (IDR)

(5)

TAXABLE YEAR

ATTACHMENT-II

TOTAL (IDR)
(6) = (3) + (4) + (5)

1. 2.

PURCHASE OF MATERIAL/MERCHANDISE SALARIES, WAGES, BONUSES, GRATIFICATION, HONORARIUM, AND OTHERS TRANSPORTATION EXPENSE DEPRECIATION AND AMORTIZATION EXPENSE RENT EXPENSES INTEREST EXPENSES EXPENSE RELATED TO SERVICE BAD DEBT EXPENSE ROYALTIES EXPENSE MARKETING AND PROMOTION EXPENSE OTHER EXPENSES BEGINNING INVENTORY ENDING INVENTORY (-/-) TOTAL OF LINE 1 TO 12 MINUS LINE 13 Note : h Number 1 for Trading Company fill with Inventory, for industry fill with purchase of material, indirect material and finished good. h Number 7 includes management fee, technical assistance fee, and other services. h Line 11 includes total expenses not covered in Line 1 to 10. h Line 12 and 13 for tradingcompanies, filled with beginning/ending balances of merchandise inventory, for industrial companies, filled with beginning/ending balances of raw materials, indirect materials, work in process, and finished goods inventory.

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

D.1.1.32.54

2 0

TOTAL (IDR)
(6) = (3) + (4) + (5)

FORM

1771 - III
MINISTRY OF FINANCE DIRECTORATE GENERAL OF TAXES TIN ACCOUNTING PERIOD

ATTACHMENT- III
CORPORATE ANNUAL INCOME TAX RETURN
FOREIGN TAX CREDIT
TAXPAYER'S NAME to WITHHOLDING OBJECT :

IDENTITY

: :

WITHHOLDING RECEIPT/TAX PAYMENT SLIP (S INCOME TAX WITHHELD (IDR) (IDR)

(4) (5)

NO
(1)

NAME AND TIN WITHHOLDING AGENT

(2)

TYPES OF INCOME/TRANSACTION
(3)

NUMBER
(6)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. dst TOTAL TTL

Notes : h Filled with calculation of each Withholding Tax Receipt. h Copy of Total Income Tax Article 22, Income Tax Article 23 and Income Tax Article 26 column (5) to Form 1771 Letter C Line 8.a. IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED D.1.1.32.32

Page -

TAXABLE YEAR

2 0

WITHHOLDING RECEIPT/TAX PAYMENT SLIP (SSP)/SSPCP DATE

(7)

from

page Attachment-III

FORM

1771 - IV
MINISTRY OF FINANCE DIRECTORATE GENERAL OF TAXES

TAXABLE YEAR (3)

ATTACHMENT - IV
CORPORATE ANNUAL INCOME TAX RETURN
FINAL INCOME TAX AND NON-TAXABLE INCOME

2 0

IDENTITY

TIN TAXPAYER'S NAME ACCOUNTING PERIOD

: : : to

PART A : FINAL INCOME TAX NO

(1)

TYPES OF INCOME INTEREST INCOME ON TIME DEPOSITS/OTHER SAVINGS AND DISCOUNT OF CENTRAL BANK'S SERTIFICATE/SECURITIES STATE INTEREST/DISCOUNT OF BOND INCOME FROM SALES VALUES OF SHARE TRADED IN STOCK EXCHANGE INCOME FROM SALES VALUE OF VENTURE CAPITAL FROM SHARE INCOME DISTRIBUTOR/DEALER/AGENT OF OIL PRODUCTS INCOME FROM TRANSFER VALUE OF RIGHT ON LAND/BUILDING INCOME FROM LEASE/RENT VALUE OF LAND/BUILDING CONSTRUCTION RELATED FEE : a. b. c. CONTRUCTOR DESIGNER CONSTRUCTION SUPERVISOR
(2)

TAX BASE (IDR)

(3)

RATE (%)
(4)

INCOME TAX PAYABLE (IDR)

(5)

1.

2.

3. 4. 5. 6. 7. 8.

9. 10. 11. 12. 13. 14. etc

GROSS SALES OF REPRESENTATIVE OFFICE GROSS INCOME OF FOREIGN SHIPPING/AIRLINES COMPANY GROSS INCOME OF DOMESTIC SHIPPING COMPANY REVALUATION OF FIXED ASSETS\ DERIVATIVE TRANSACTION TRADE IN CAPITAL MARKET

TOTAL PART A

TPA
Copy of Form 1771 letter F line 15 point a

PART B : NON-TAXABLE INCOME NO

(1)

TYPES OF INCOME
(2)

GROSS INCOME (IDR)

1. 2. 3. 4.

AID/DONATION GRANT DIVIDEND FROM INVESTMENT/OWNERSHIP OF SHARES OF THE INDONESIAN BUSINESS ENTITIES (Article 4 Paragraph (3) Item f of Income Tax Law) CONTRIBUTION AND SPECIFIC INCOME RECEIVED BY A PENSION FUND

5.

SHARES OF PROFIT RECEIVED BY VENTURE CAPITAL COMPANIES FROM ITS PARTNERS

6.

EXCESS INCOME RECEIVED BY NONPROFIT AND REGISTERED EDUCATION INSTITUTION OR RESEARCH AND DEVELOPMENT ESTABLISHMENT WHICH ARE REINVESTED IN THE FORM OF FACILITIES AND IN INFRASTRUCTURE FOR EDUCATIONAL AND/OR R&D ACTIVITIES

7. etc TOTAL PART B TPB

Copy to Form 1771 letter F line 15 point b IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED Page from page Attachment-IV

D.1.1.32.34

FORM

1771 - V
MINISTRY OF FINANCE

CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

ATTACHMENT - V

h LIST OF SHAREHOLDERS/CAPITAL OWNERS AND TOTAL DIVIDENDS DISTRIBUTED DIRECTORATE GENERAL OF TAXESh LIST OF DIRECTORS AND COMMISSIONERS

2 0

IDENTITY

TIN TAXPAYER'S NAME

: : to

ACCOUNTING PERIOD :

PART A : LIST OF SHAREHOLDERS/CAPITAL OWNERS AND TOTAL DIVIDENDS DISTRIBUTED NO

(1)

NAME AND ADDRESS

(2)

TIN
(3)

TOTAL PAID IN SHARES (IDR)

(4)

%
(5)

DIVIDEND (IDR)
(6)

1.

2.

3.

4.

5. 6.

7.

8.

9.

10. dst

TOTAL PART A

TPA

100%

PART B : LIST OF DIRECTORS AND COMMISSIONERS NO

(1)

NAME AND ADDRESS

(2)

TIN
(3)

POSITION
(4)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10. dst
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED Page from page Attachment-V

D.1.1.32.35

FORM

CORPORATE ANNUAL INCOME TAX RETURN

h LIST OF CAPITAL CONTRIBUTION IN AFFILIATION COMPANIES h LIST OF ACCOUNT RECEIVABLE TO SHAREHOLDERS AND/OR AFFILIATION COMPANIES

TAXABLE YEAR

1771 - VI
MINISTRY OF FINANCE

ATTACHMENT - VI

2 0

h LIST OF ACCOUNT PAYABLE FROM SHAREHOLDERS AND/OR AFFILIATION COMPANIES DIRECTORATE GENERAL OF TAXES

IDENTITY

TIN TAXPAYER'S NAME

: :
to

ACCOUNTING PERIOD :

PART A : LIST OF CAPITAL CONTRIBUTION IN AFFILIATION COMPANIES NO

(1)

NAME AND ADDRESS

(2)

TIN
(3)

AMOUNT OF CAPITAL CONTRIBUTION (IDR)

(4)

%
(5)

1. 2. 3. 4. 5. etc TOTAL TTL

PART B : LIST OF ACCOUNT PAYABLE FROM SHAREHOLDERS AND/OR AFFILIATION COMPANIES NO

(1)

NAME AND ADDRESS

(2)

TIN
(3)

TOTAL LOAN (IDR)

(4)

YEAR
(5)

INTEREST/ YR % (6)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12 etc PART C : LIST OF ACCOUNT RECEIVABLE TO SHAREHOLDERS AND/OR AFFILIATION COMPANIES NO
(1)

NAME AND ADDRESS

(2)

TIN
(3)

TOTAL LOAN (IDR)

(4)

YEAR
(5)

INTEREST/ YR % (6)

1. 2. 3. 4. 5. 6. 7. 8.

9. 10. 11. 12 dst

IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED Page from page Attachment-VI

D.1.1.32.36

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN FOR TAXABLE YEAR 2 0
LIST OF FISCAL DEPRECIATION AND AMORTIZATION
TIN : MONTH/ GROUP / TYPES OF ASSETS YEAR OF ACQUISITION COST OF ACQUISITION (IDR) TAXPAYER'S NAME : DEPRECIATION/AMORTIZATION METHOD COMMERCIAL VALUE FISCAL
FISCAL DEPRECIATION/AMORTIZATION

1A

BEGINNING BALANCE (IDR)

IN CURRENT YEAR (IDR)

NOTE

TANGIBLE ASSETS Group 1 : . Group 2 : . Group 3 : . Group 4 : . BUILDINGS Permanent : . Not Permanent : . TOTAL DEPRECIATION (For Tax Purpose)............................ TOTAL COMMERCIAL DEPRECIATION........................ DIFFERENCE (COPY TO FORM 1771-I LINE 5 LETTER I OR LINE 6 LETTER a)............. INTANGIBLE ASSETS Group 1 : . Group 2 : . Group 3 : . Group 4 : . Other Group . TOTAL AMORTIZATION (For Tax Purpose)........................... TOTAL COMMERCIAL AMORTIZATION.......................... DIFFERENCE (COPY TO FORM 1771-I LINE 5 LETTER j OR LINE 6 LETTER b)............. .. TAXPAYER/AUTHORIZED REPRESENTATIVE

( .)

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR 2 0 FISCAL LOSS CARRIED FORWARD CALCULATION FOR TAX PURPOSE FOR TAXABLE YEAR AND CURRENT TAXABLE YEAR TIN : LOSS AND FISCAL NET INCOME NO YEAR. (IDR) (1) 1 (2) (3) (4) YEAR. (IDR) (5) TAXPAYER'S NAME : KOMPENSASI KERUGIAN FISKAL YEAR. (IDR) (6) YEAR. (IDR) (7) YEAR.
(THIS TAXABLE YEAR)

2A

YEAR

IDR

YEAR.
(CURRENT TAXABLE YEAR)

IDR*) (8)

IDR**) (9)

5 etc TOTAL TTL

NOTE : *) COPY THE AMOUNT OF THISS COLUMN TO FORM 1771 LETTER A LINE 2 **) COPY THE AMOUNT OF THIS COLUMN TO FORM 1771 LETTER E LINE 14 POINT b

.,
TAXPAYER/AUTHORIZED REPRESENTATIVE

(..)

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

3A

STATEMENT OF TRANSACTION WITH RELATED PARTIES

TIN : TAXPAYER'S NAME : : I LIST OF RELATED PARTIES No 1 2 3 4 5 II DETAILS OF TRANSACTION WITH RELATED PARTIES No 1 2 3 4 5 Name a a a a a b b b b b Types of Transaction c c c c c d d d d d e e e e e f f f f f g g g g g , IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED TAXPAYER/AUTHORIZED REPRESENTATIVE Transaction's Value Determination of Price Method shall be used Determination of Methods Name Address Tax Identification Number (TIN) Business Activities

Types of Relationship with Taxpayer

1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4

()

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

3A-1

STATEMENT OF TRANSACTION IN RELATED PARTIES

TIN :

TAXPAYER'S NAME/PERMANENT : ESTABLISHMENT

DOCUMENTATION OF ARM'S LENGTH TRANSACTION DETERMINATION These are some particular notes that we made to support the fact that transactions that have been made with related parties are in accordance with the arm's length principle and the common practice.

Concerning of Company's description in detail That we have made note about :

Yes

No Ownership structure that refer to the dependability between all company in a one group of multinational company. Organizational structure of Taxpayer Company Operating aspects from Taxpayers business operations including details of functions which is delivered by units in the Taxpayers organization Description of business environment in detail

Concerning of Transaction That we have made note about : Yes No Transaction with related parties Taxpayer's transaction with company which is not influenced by related parties or information about comparing transaction. In case, tax payers act as the selling, rendering, or borrowing party in the above transactions, we have conducted record as follows : Pricing Policy and price list for the last 5 (five) years. Details of manufacturing cost or acquisition cost or service preparation on cost.

Concerning of Comparation Analysis Result Notes That we have made note about :

Yes

No Characteristic of product (goods, service, loans, finance instrument, etc) which has been transacted Functional Analysis which is the primary consideration of tax payer's transactions with related parties companies, all risks assumed and assets are being used in those transactions. The economic conditions when transactions happened. Term of transactions, including agreement between taxpayer's with related parties from foreign countries. Taxpayer business strategy at the time when carry out the affiliation transaction

Concerning of determination of Fair Price That we have made note about :

Yes

No Methodology of price determination which applicable by Taxpayer, which shows how the fair price is acquired, and the reasons why this method is chosen, compared to other methods. Comparator Data used by the Taxpayer to determine of transfer price The Application of the determination methodology of transfer price and the use of comparing data in the determination or tansfer price.

TAXPAYER/AUTHORIZED REPRESENTATIVE

________________________________

3A-1

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

3A-2

STATEMENT OF TRANSACTION WITH PARTIES OF TAX HAVEN COUNTRY RESIDENT

TIN
:

TAXPAYER'S :NAME
I IN CASE THE COMPANY HAS MADE TRANSACTION WITH PARTIES OF TAX HAVEN COUNTRY RESIDENT IN THIS TAXABLE YEAR No 1 2 3 4 5 Name of Transaction Colleagues a a a a a b b b b b Types of Transaction c c c c c d d d d d e e e e e f f f f f g g g g g Country Transaction Value

II DETERMINATION OF TRANSACTION VALUE ABOVE, SHALL BE REFERRED TO THE TERM ARMS LENGTH ANG ORDINARY BUSINESS PRINCIPLE YES NO TAXPAYER/AUTHORIZED REPRESENTATIVE

( .. )

IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR 2 0

LIST OF INVESTMENT FACILITIES
TIN TAXPAYER'S NAME
1.

4A

: :

IN CASE THE COMPANY HAS BEEN GRANTED TAX FACILITIES ON INVESTMENT, PLEASE EXPLAIN : a. LETTER OF APPROVAL FROM BKPM 1 2 NUIMBER DATE : : .. .. b. 1 2 MINISTER OF FINANCE DECREE NUIMBER DATE : : : : : : 2a1a 2a1b 2a2 2a3 *) .. ..

2.

a.

AMOUNT OF INVESTMENT APPROVED :

1. a. IN FOREX b. EQUIVALENT IDR 2. 3. IND IDR. TOTAL IDR. 2

b. c.

INVESTMENT FIELD AND/OR REGION OF INVESTMENT

: :

NEW

EXPANSION

d.

FACILITIES GRANTED

1 2 3 5

INVESTMENT ALLOWANCE ACCELERATED DEPRECIATION/AMORTIZATION LOSS CARRIED FORWARD 4 YEAR

10% TAX ON DIVIDENDS PAID TO FOREIGN SHAREHOLDERS

3.

INVESTMENT REALIZATION a. b. THIS YEAR UP TO THIS YEAR : : Rp. Rp. a b

4. 5.

TIME WHEN COMMERCIAL PRODUCTION STARTED (CPS), DATE : FACILITIES OF INVESTMENT ALLOWANCE : YEAR a b IDR. **)

(5% X REALIZATION OF INVESTMENT UP TO CPS)

NOTE : *) **) PLEASE USE ACTUAL CONVERTION RATE AT THE TIME OF TRANSFER TO THE COMPANY'S ACCOUNT COPY THE AMOUNT IN LINE 5 b TO FORM 1771-I LINE 7 COLUMN (3)
TAXPAYER/AUTHORIZED REPRESENTATIVE

..,

( ... )

4A

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR 2 0

LIST OF BRANCH MAJOR
TIN TAXPAYER'S NAME : :

5A

NUMBER NO (1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 dst. NOTE : IF NEEDED, ADDITIONAL PAGES MAY BE ADDED , TAXPAYER/AUTHORIZED REPRESENTATIVE ADDRESS OF MAIN BRANCHES OFFICE (2) TIN LOCATION (3) OF MAIN BRANCHES (4)

(.)

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR 2 0

CALCULATION OF INCOME TAX ARTICLE 26 PARAGRAPH (4)
TIN : TAXPAYER'S NAME/PERMANENT ESTABLISHMENT : IDR 1. 2. COMMERCIAL NET INCOME : (BASED ON FINANCIAL STATEMENT) FISCAL ADJUSTMENTS a. POSITIVE b. NEGATIVE c. TOTAL (a b) 3. 4. 5. 6. : : IDR. : IDR. : 2a 2b 2c 3 4 1

6A

FISCAL NET INCOME : (1 + 2c) ... CORPORATE INCOME TAX PAYABLE :

TAX BASE FOR INCOME TAX ART.26 PARAGRAPH (4) : (3 - 4) 5 INCOME TAX ARTICLE 26 PARAGRAPH (4) a b PAYABLE : *) % X AMOUNT IN LINE 5 NOT PAYABLE, BECAUSE : c d PROVISIONS OF TAX TREATY INDONESIA - .. REINVESTED WHOLLY IN INDONESIA IN A NEW LIMITED COMPANY : **) .. TIN ADDRESS : : e f .... .... g CITY : .. POSTAL CODE : h 6

NOTE : *) TAX RATE OF 20% RATE STIPULATED IN TAX TREATY **) PLEASE ATTACH THE DOCUMENTATION OF REINVESTMENT

.., TAXPAYER/AUTHORIZED REPRESENTATIVE

()

SPECIAL ATTACHMENT CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

7A

2 0
FOREIGN TAX CREDIT
TIN : TAXPAYER'S NAME NET AMOUNT (IDR) : TAX DUE/PAID IN FOREIGN COUNTRY RUPIAH VALAS (5) (6)

TAX CREDITABLE (IDR) (7)

NO.

NAME AND ADDRESS OF FOREIGN WITHHOLDING AGENT

TYPE OF INCOME

(1) 1 2 3 4 5 6 7 8 9 10 dst. JUMLAH

(2)

(3)

(4)

JML

, NOTE : * PLEASE FILL WITH THE DETAIL OF EACH WITHHOLDING RECEIPT/TAX PAYMENT * COLUMN (5) IDR FILL WITH CONVERTION VALUR\E FROM THE NUMBER IN COLUMN (6) FOREX WITH USING EXCHANGE RATE PREVAILING AT THE TIME OF TAX PAYMENT/DUE IN FOREIGN COUNTRY * TAX CREDIT THAT CAN BE CREDITED IN COLUMN (7) SHALL BE CALCULATED USING ORDINARY CREDIT PER COUNTRY BASIS METHOD * PLEASE COPY THE TOTAL AMOUNT OF COLUMN (7) TO FORM 1771 LETTER C LINE 8.b. * PLEASE COPY THE TOTAL AMOUNT OF COLUMN (4) TO FORM 1771-I LINE 2. * IF NEEDED, ADDITIONAL PAGES MAY BE ADDED. TAXPAYER/AUTHORIZED REPRESENTATIVE

(.)

SPECIAL ATTACHMENT

8A-1
TAXABLE YEAR

8A-1

INDUSTRIAL COMPANIES

CORPORATE ANNUAL INCOME TAX RETURN

TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT

TIN TAXPAYER'S NAME

: :

I. ELEMENTS FROM BALANCE SHEET NO.

1. 2. 3. 4. 5. 6. 7. 8.

DESCRIPTION
CASH AND EQUIVALENT TEMPORARY INVESTMENTS ACCOUNT RECEIVABLES-THIRD PARTIES ACCOUNT RECEIVABLES-RELATED PARTIES ACCOUNT RECEIVABLE-THIRD PARTIES OTHER RECEIVABLE - RELATED PARTIES ALLOWANCE FOR DOUBTFUL ACCOUNTS INVENTORIES

VALUE (IDR)

NO.
1. 2. 3. 4. 5. 6. 7. 8.

DESCRIPTION
ACCOUNT PAYABLE - THIRD PARTIES ACCOUNTS PAYABLE-RELATED PARTIES INTEREST PAYABLE TAXES PAYABLE DIVIDENDS PAYABLE ACCRUED EXPENSES SHORT-TERM BANK LOANS LONG TERM DEBTS-CURRENT MATURITIES

VALUE (IDR)

9. PREPAID EXPENSES 10. ADVANCES 11. OTHER CURRENT ASSETS 12. LONG - TERM RECEIVABLES 13. LAND AND BUILDINGS 14. 15. 16. 17. 18. 19. 20. OTHER FIXED ASSETS LESS : ACCUMULATED DEPRECIATION INVESTMENT IN ASSOCIATES OTHER LONG -TERM INVESTMENTS INTANGIBLE ASSETS DEFERRED TAX ASSETS OTHER NON-CURRENT ASSETS TOTAL ASSETS

9. ADVANCES 10. OTHER CURRENT-LIABILITIES 11. LONG-TERM DEBT-BANK LOANS 12. LONG-TERM DEBT-THIRD PARTIES 13. LONG-TERM DEBT-RELATED PARTIES 14. 15. 16. 17. 18. 19. 20. DEFERRED TAX LIABILITIES OTHER NON-CURRENT LIABILITIES CAPITAL STOCK ADDITIONAL PAID-IN CAPITAL RETAINED EARNING FROM PREVIOUS YEAR RETAINED EARNINGS OTHER EQUITY TOTAL LIABILITIES AND OWNER'S EQUITY

II. ELEMENTS FOM INCOME STATEMENT NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.

DESCRIPTION
NET SALES MATERIALS DIRECT LABOUR FACTORY OVERHEAD MANUFACTURING COST (2 + 3 + 4) WORK IN PROCESS-BEGINNING WORK IN PROCESS-ENDING COST OF GOOD MANUFACTURE (5 + 6 - 7) FINISHED GOODS-BEGINNING FINISHED GOODS-ENDING COST OF GOOD SOLD (8 + 9 - 10) GROSS PROFIT (1 - 11) SELLING EXPENSES GENERAL AND ADMINISTRATIVE EXPENSES PROFIT (12 - 13 - 14) OTHERS INCOME (EXPENSES) NET EARNINGS OF ASSOCIATES INCOME BEFORE INCOME TAX BENEFIT/(EXPENSE) (15 + 16 + 17) INCOME TAX BENEFIT/(EXPENSE) NET EARNINGS FROM NORMAL ACTIVITIES (18 - 19) EXTRAORDINARY ITEMS INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (20 + 21) MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES NET PROFIT (22 - 23)

VALUE (IDR)

III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7 NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)

DECLARATION Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever. a. .,
(Place) (date) (month) (year)

b. c.

TAXPAYER

AUTHORIZED/REPRESENTATIVE

FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)

SPECIAL ATTACHMENT

8A-2

TRADING COMPANIES

CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT

: :

TIN TAXPAYER'S NAME

I. ELEMENTS FROM BALANCE SHEET NO.

1. 2. 3. 4. 5. 6. 7. 8.

DESCRIPTION
CASH AND EQUIVALENT TEMPORARY INVESTMENTS ACCOUNT RECEIVABLES-THIRD PARTIES ACCOUNT RECEIVABLES-RELATED PARTIES ACCOUNT RECEIVABLE-THIRD PARTIES OTHER RECEIVABLE - RELATED PARTIES ALLOWANCE FOR DOUBTFUL ACCOUNTS INVENTORIES

VALUE (IDR)

NO.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

DESCRIPTION
ACCOUNT PAYABLE - THIRD PARTIES ACCOUNTS PAYABLE-RELATED PARTIES INTEREST PAYABLE TAXES PAYABLE DIVIDENDS PAYABLE ACCRUED EXPENSES SHORT-TERM BANK LOANS LONG TERM DEBTS-CURRENT MATURITIES ADVANCES OTHER CURRENT-LIABILITIES LONG-TERM DEBT-BANK LOANS LONG-TERM DEBT-THIRD PARTIES

VALUE (IDR)

9. PREPAID EXPENSES 10. ADVANCES 11. OTHER CURRENT ASSETS 12. LONG - TERM RECEIVABLES 13. LAND AND BUILDINGS 14. 15. 16. 17. 18. 19. 20. OTHER FIXED ASSETS LESS : ACCUMULATED DEPRECIATION INVESTMENT IN ASSOCIATES OTHER LONG -TERM INVESTMENTS INTANGIBLE ASSETS DEFERRED TAX ASSETS OTHER NON-CURRENT ASSETS TOTAL ASSETS

13. LONG-TERM DEBT-RELATED PARTIES 14. 15. 16. 17. 18. 19. 20. DEFERRED TAX LIABILITIES OTHER LONG - TERM LIABILITIES CAPITAL STOCK ADDITIONAL PAID-IN CAPITAL RETAINED EARNING FROM PREVIOUS YEAR RETAINED EARNINGS OTHER EQUITY TOTAL LIABILITIES AND OWNER'S EQUITY

II. ELEMENTS FOM INCOME STATEMENT NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

DESCRIPTION
NET SALES PURCHASE MERCHANDISE INVENTORY - BEGINNING MERCHANDISE INVENTORY - ENDING COST OF GOOD SOLD (2 + 3 - 4) GROSS PROFIT (1 - 5) SALES EXPENSE GENERAL AND ADMINISTRATIVE EXPENSES PROFIT (6 - 7 - 8) INCOME/(EXPENSE) OTHER NET EARNINGS OF ASSOCIATES INCOME BEFORE INCOME TAX (9 + 10 +11) INCOME TAX BENEFIT (EXPENSE) NET EARNINGS FROM NORMAL ACTIVITIES (12 - 13) EXTRAORDINARY ITEMS GAIN/LOSS BEFORE MINORITY INTEREST (14 + 15) MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES NET PROFIT (16 - 17)

VALUE (IDR)

III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7 NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)

DECLARATION Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever. a. .,
(Place) (date) (month) (year)

b. c.

TAXPAYER

AUTHORIZED/REPRESENTATIVE

FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)

8A-2
TAXABLE YEAR

(IDR)

(IDR)

All Attachments

(year)

y Seal)

SPECIAL ATTACHMENT

8A-3

CONVENTIONAL BANKS

CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT

: :

TIN TAXPAYER'S NAME

I. ELEMENTS FROM BALANCE SHEET NO.

1. 2. 3. 4. 5. 6. 7. 8. CASH GIRO AT CENTRAL BANK GIRO AT OTHER BANK - NET PLACEMENTS ON CENTRAL BANK - NET PLACEMENT ON OTHER BANKS- NET MARKETABLE SECURITIES - RELATED PARTIES MARKETABLE SECURITIES - THIRD PARTIES MARKETABLE SECUTIRIES PURCHASED UNDER RESALE AGREEMENT, NET OF ALLOWANCE

DESCRIPTION

VALUE (IDR)

NO.
1. 2. 3. 4. 5. 6. 7. 8.

DESCRIPTION
OBLIGATION DUE IMMEDIATELY DEPOSITS FROM CUSTOMERS - RELATED PARTIES DEPOSITS FROM CUSTOMERS - THIRD PARTIES DEPOSITS FROM OTHER BANKS MARKETABLE SECURITIES SOLD UNDER REPURCHASE AGREEMENTS, NET OF ALLOWANCE DERIVATIVE PAYABLES ACCEPTANCE PAYABLES TAXES PAYABLE

VALUE (IDR)

9. DERIVATIVE RECEIVABLES, NET OF ALLOWANCE 10. LOANS, NET OF ALLOWANCE 11. 12. CONSUMER FINANCING RECEIVABLES, NET OF ALLOWANCE ACCEPTANCE ALLOWANCE RECEIVABLES, NET OF

9. MARKETABLE SECURITIES ISSUED 10. LOAN RECEIVED 11. ESTIMATED LOSSES ON COMMITMENTS AND CONTIGENCIES

12. DEFERRED TAX LIABILITY 13. ACCRUALS LIABILITIES 14. OTHER LIABILITIES 15. SUBORDINATED DEBTS 16. 17. 18. 19. 20. CAPITAL STOCK ADDITIONAL-PAID IN CAPITAL RETAINED EARNING FROM PREVIOUS YEAR RETAINED EARNINGS OTHER EQUITY TOTAL LIABILITIES AND OWNER'S EQUITY

13. GOVERNMENT BONDS 14. INVESTMENTS, NET OF ALLOWANCE GOODWILL NET OF ACCUMULATED 15. AMORTIZATION 16. 17. 18. 19. 20. FIXED ASSET LESS : ACCUMULATED DEPRECIATION DEFERRED TAX ASSETS PREPAID EXPENSES OTHER ASSETS TOTAL ASSETS

II. ELEMENTS FOM INCOME STATEMENT NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

DESCRIPTION
INTEREST INCOME INTEREST EXPENSE NET INTEREST INCOME (1 - 2) OTHER OPERATING INCOME OTHER OPERATING EXPENSES INCOME FROM OPERATIONS(4 - 5) NON-OPERATING INCOME NON-OPERATING EXPENSE NON-OPERATING INCOME-NET (7 - 8) NET EARNINGS OF ASSOCIATES INCOME BEFORE INCOME TAX (3 + 6 + 9 + 10) INCOME TAX BENEFIT (EXPENSE) GAIN (LOSS) FROM NORMAL ACTIVITIES (12 - 13) EXTRAORDINARY ITEMS INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (13-14) MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES NET PROFIT (15 - 16)

VALUE (IDR)

III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7 NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)

DECLARATION Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever. a. .,
(Place) (date) (month) (year)

b. c.

TAXPAYER

AUTHORIZED/REPRESENTATIVE

FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)

8A-3
TAXABLE YEAR

(IDR)

(IDR)

All Attachments

(year)

y Seal)

SPECIAL ATTACHMENT

8A-4

SHARIA BANKS

CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT

: :

TIN TAXPAYER'S NAME

I. ELEMENTS FROM BALANCE SHEET NO.

1. 2. 3. 4. 5.

DESCRIPTION
CASH AND CASH EQUIVALENT PALCEMENTS AT CENTRAL BANK GIRO AT OTEHRS BANK - NET

VALUE (IDR)

NO.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

DESCRIPTION
OBLIGATION DUE IMMEDIATELY DEPOSIT (WADIAH SAVING AND GIRO) OTHER LIABILITY (SALAM LIABILITY AND ISTISHNA LIABILITY) LIABILITY TO OTHER BANK RECEIVED FINANCING UNDISTRIBUTED OF PROFIT ANNOUNCED ZAKAT PAYABLE TAX PAYABLE DFERRED TAX LIABILITIES OTHET PAYABLE

VALUE (IDR)

PLACEMENT AT OTHER BANK - NET SECURITIES RECEIVABLES (MURABAHAH, SALAM ISTISHNA, 6. IJAROH, ETC) 7. MUDHARABAH FINANCING 8. MUSYAROKAH FINANCING 9. INVENTORIES (ASSET FOR RESALES) 10. ASSETS ACQUIRED FOR IJARAH 11. ISTISHNA ASSET IN COMPLETION 12. INVESTMENT 13. 14. 15. 16. 17. FIXED ASSET LESS : ACCUMULATED DEPRECIATION DEFERRED TAX ASSETS PREPAID EXPENSES OTHER ASSETS TOTAL ASSETS

11. (MUDAROBAH DEPOSIT AND SAVING) NON BANK 12. (MUDHARABAH DEPOSIT AND SAVING) BANK 13. 14. 15. 16. 17. CAPITAL STOCK ADDITIONAL PAID-IN CAPITAL PREVIOUS RETAINED EARNING RETAINED EARNING FOR THIS YEAR OTHER EQUITY TOTAL LIABILITIES AND OWNER'S EQUITY

II. ELEMENTS FOM INCOME STATEMENT NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

DESCRIPTION
OPERATING AVENUE RIGHT OF THIRD PARTIES ON THE UNRELATED INVESTMENT RETURN] MAJOR OPERATIONS INCOME-NET(1 - 2) OTHER OPERATING AVENUE OTHER OPERATING EXPENSES INCOME FROM OPERATIONS (3 + 4 - 5) NON-OPERATING REVENUE NON-OPERATING EXPENSES NET EARNINGS OF ASSOCIATES INCOME BEFORE INCOME TAX (6 + 7 - 8 + 9) INCOME TAX BENEFIT (EXPENSE) NET EARNINGS FROM NORMAL ACTIVITIES (10 - 11) EXTRAORDINARY ITEMS INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (12-13) MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES NET PROFIT (14 - 15)

VALUE (IDR)

III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7 NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)

DECLARATION Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever. a. .,
(Place) (date) (month) (year)

b. c.

TAXPAYER

AUTHORIZED/REPRESENTATIVE

FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)

8A-4
TAXABLE YEAR

(IDR)

(IDR)

All Attachments

(year)

y Seal)

SPECIAL ATTACHMENT

8A-5

INSURANCE COMPANY

CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT

: :

TIN TAXPAYER'S NAME

I. ELEMENTS FROM BALANCE SHEET NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

URAIAN
INVESTMENTS-TIME DEPOSITS INVESMENTS IN SHARES OF STOCK INVESTMENTS-BONDS INVESTMENTS-TRADING SECURITIES INVESTMENTS-DIRECT SHARE INVESTMENTS-LAND AND BUILDING INVESTMENTS-MORTGAGES POLICY LOAN INVESTMENTS-INSURANCE POLICY LOANS OTHER INVESTMENTS CASH ON HAND AND IN BANKS PREMIUM RECEIVABLES RE-INSURANCE RECEIVABLES INVESTMENT RETURN RECEIVABLE OTHER ACCOUNT RECEIVABLES PREPAID EXPENSES

NILAI (RUPIAH)

NO.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

URAIAN
OBLIGATION TO POLICYHOLDERS OBLIGATION FOR FUTURE POLICY BENEFITS ESTIMATED OWN RETENTION CLAIMS CLAIMS PAYABLE UNEARNED PREMIUMS TOTAL OBLIGATION TO POLICYHOLDER DEPOSIT PREMIUMS COMMISION PAYABLES RE-INSURANCE PAYABLES ACCRUED EXPENSES TAXES PAYABLE DEFERRED TAX LIABILITY OTHER LIABILITIES CAPITAL STOCK ADDITIONAL PAID-IN CAPITAL
DIFFERENCE IN VALUE RESULTING FROM RESTRUCTURING

NILAI (RUPIAH)

16. DEFERRED TAX ASSET 17. FIXED ASSET 18. LESS : ACCUMULATED DEPRECIATION 19. DEFERRED ACQUISITION COST-NET 20. OTHER ASSETS TOTAL ASSETS

16. TRANSACTION WITH ENTITIES UNDER COMMON CONTROL 17. DIFFERENCE ON REVALUATION OF FIXED ASSET 18. IN FAIR VALUE OF AVAILABLE FOR SALE SECURITIES 19. RETAINED EARNINGS 20. OTHER EQUITY TOTAL LIABILITIES AND OWNER'S EQUITY

NET UNREALIZED GAIN(LOSS) ON INCREASE (DECREASE)

II. ELEMENTS FOM INCOME STATEMENT NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

DESCRIPTION
GROSS PREMIUMS REINSURANCE PREMIUMS DECREASE(INCREASE) IN UNEARNED PREMIUMS TOTAL PREMIUMS INCOME (1 + 2 + 3) NET INCOME FROM INVESTMENTS OTHERS TOTAL INCOME (4 + 5 + 6) CLAIMS AND BENEFITS RE-INSURANCE CLAIMS INCREASE IN FUTURE POLICYHOLDER BENEFIT LIABILITIES AND ESTIMATED CLAIMS LIABILITIES ACQUISITION COST OPERATING EXPENSES SELLING EXPENSES GENERAL AND ADMINISTRATIVE EXPENSE OTHER EXPENSES TOTAL EXPENSES (TOTAL 8 TO 15) INCOME FROM OPERATIONS (7-16) NET EARNINGS OF ASSOCIATES INCOME BEFORE INCOME TAX BENEFIT/(EXPENSE) (17 + 18) INCOME TAX BENEFIT/(EXPENSE) GAINS (LOSSES) FROM NORMAL ACTIVITIES (19 - 20) EXTRAORDINARY ITEMS INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (21+22) MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES NET PROFIT (23-24)

VALUE (IDR)

III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7 NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)

DECLARATION Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever. a. .,
(Place) (date) (month) (year)

b. c.

TAXPAYER

AUTHORIZED/REPRESENTATIVE

FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)

8A-5
TAXABLE YEAR

UPIAH)

(IDR)

All Attachments

(year)

y Seal)

SPECIAL ATTACHMENT

8A-6

NONQUALIFICATION

CORPORATE ANNUAL INCOME TAX RETURN

TAXABLE YEAR

TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT

: :

TIN TAXPAYER'S NAME

I. ELEMENTS FROM BALANCE SHEET NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

DESCRIPTION
CASH AND EQUIVALENT TEMPORARY INVESTMENT ACCOUNT RECEIVABLE-THIRD PARTIES ACCOUNT RECEIVABLE-RELATED PARTIES ACCOUNT RECEIVABLE-THIRD PARTIES OTHER RECEIVABLE WITH RELATED PARTIES ALLOWANCE FOR DOUBTFUL ACCOUNTS INVENTORIES PREPAID EXPENSES PURCHASING DOWN PAYMENT OTHER CURRENT ASSET LONG - TERM RECEIVABLE

VALUE (IDR)

NO.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

DESCRIPTION
ACCOUNT PAYABLE - THIRD PARTIES ACCOUNT PAYABLE-RELATED PARTIES INTEREST PAYABLE INTEREST TAXES DIVIDEND PAYABLE ACCRUED EXPENSES BANK PAYABLES LONG-TERM DEBITS-CURRENT MATURITIES ADVANCES OTHER CURRENT-LIABILITIES LONG-TERM DEBT-BANK LOANS LONG-TERM DEBT-THIRD PARTIES

VALUE (IDR)

13. LAND AND BUILDING 14. OTHER FIXED ASSETS 15. ACCUMULATED DEPRECIATION 16. INVESTMENT IN ASSOCIATION COMPANY 17. OTHER LONG -TERM INVESTMENT 18. INTANGIBLE ASSET 19. DEFERRED TAX ASSETS 20. OTHER NON-CURRENT ASSET TOTAL ASSETS

13. LONG-TERM DEBT-RELATED PARTIES 14. DEFERRED TAX LIABILITIES 15. OTHER NON-CURRENT LIABILITIES 16. CAPITAL STOCK 17. ADDITIONAL PAID-IN CAPITAL 18. RETAINED EARNING FROM PREVIOUS YEAR 19. RETAINED EARNING 20. OTHER EQUITY TOTAL LIABILITIES AND OWNER'S EQUITY

II. ELEMENTS FOM INCOME STATEMENT NO.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

DESCRIPTION
NET SALES BEGINNING INVENTORY PURCHASE ENDING INVENTORY COST OF GOOD SOLD (2 + 3 -4) GROSS PROFIT (1 - 5) SALES EXPENSE GENERAL AND ADMINISTRATIVE EXPENSE PROFIT (6 - 7 - 8) INCOME/(EXPENSE) OTHER NET EARNINGS FROM ASSOCIATES INCOME BEFORE INCOME TAX (9 + 10 + 11) INCOME TAX BENEFIT (EXPENSE) GAIN (LOSS) FROM NORMAL ACTIVITIES (12 - 13) EXTRAORDINARY ITEMS GAIN/LOSS BEFORE MINORITY INTEREST (14 + 15) MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES NET PROFIT (16 - 17)

VALUE (IDR)

III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7 NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)

DECLARATION Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever. a. .,
(Place) (date) (month)

0
(year)

b. c.

TAXPAYER

AUTHORIZED/REPRESENTATIVE

FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)

8A-6
TAXABLE YEAR

(IDR)

(IDR)

All Attachments

(year)

y Seal)