ANNUAL FORM

INDIVIDUAL 1770 S
INCOME TAX RETURN TAX YEAR :
FOR INDIVIDUALS WHO DO NOT CONDUCT BUSINESS /
DEPARTEMEN KEUANGAN RI
DIREKTORAT JENDERAL PAJAK INDEPENDENT WORK

 FILL IN USING BLOCK / TYPED LETTERS

 MARK “X” IN APPROPRIATE (BOX)
 FILL IN CORRECTLY, COMPLETELY AND CLEARLY ACCORDING TO THE GUIDELINES

TAX ID (N P W P) :

NAME OF TAXPAYER : .................................................................................................................

RESIDENCIAL ADDRESS : .................................................................................................................
.................................................................................................................
CITY / POST CODE : ......................................................................
OCCUPATION : ..................................................................... KLU :
TELEPHONE / FAX : .................................................................................................................

IN RUPIAH

A. NET INCOME 1. DOMESTIC NET INCOME FROM EMPLOYMENT [BROUGHT FORWARD FROM ATTACHMENT
I OF FORM 1770S PART A TOTAL COLUMN (5)] ........................................

2. OTHER DOMESTIC NET INCOME [BROUGHT FORWARD FROM ATTACHMENT I OF FORM

1770 S PART B TOTAL COLUMN (5)]..............................................................................

3. NET INCOME OVERSEAS (BROUGHT FORWARD FROM A SEPARATE

ATTACHMENT) .............................................................................................................................................
................

4. TOTAL NET INCOME ( 1+2+3 ) ....................................................................................................

B. TAXABLE 5. TITHE......................................... ......................................................................................................

INCOME 6. NON TAXABLE INCOME (PTKP) ................................................................................................

S /..... M /..... M/W/..... ASSET LIVING APART /.....

SPLIT /.....

7. TOTAL ( 5 + 6 ) ...............................................................................................................................

8. TAXABLE INCOME ( 4 – 7 ) ..........................................................................................................

C. INCOME TAX 9. INCOME TAX PAYABLE ( RATES PER ART. 17 OF INCOME TAX LAW x LETTER B NO.
8) .......................................................................................................................................................
PAYABLE 10. REFUND / DEDUCTION OF ART. 24 (OFFSHORE TAX CREDIT) WHICH HAS BEEN
CREDITED........................................................................................................................................

11. TOTAL INCOME TAX PAYABLE ( 9 + 10 ) .................................................................................

D. TAX CREDIT 12. INCOME TAX WITHHELD/COLLECTED BY OTHER PARTIES/BORNE BY GOV'T [BROUGHT
FORWARD FROM ATTACHMENT I OF FORM 1770 S PART C TOTAL COLUMN (5)] AND TAX
PAID/WITHHELD/PAYABLE OVERSEAS (BROUGHT FORWARD FROM A SEPARATE
ATTACHMENT) .........................................................................................

13. a. INCOME TAX PAYABLE BY SELF

------------------------------------------------- ( 11 – 12 ) ....................................................

b. OVERWITHHELD/OVERCOLLECTED TAX

14. TAX PAID BY SELF

a. Art. 25 paragraph (1).....................................................................................................................

b. Art. 25 Tax Collection Notice (excluding penalties).....................................................................

c. FISCAL EXIT TAX......................................................................................................................

TOTAL TAX CREDIT ( a +b+c ) .....................................................................................................

E. UNDER / OVER 15. a. UNDERPAYMENT OF TAX (ART. 29 INCOME TAX)

PAYMENT OF ------------------------------------------------------------------------------------- ( 13 – 14 ) ….….

TAX b. OVERPAYMENT OF TAX (ART. 28A INCOME TAX)

AMOUNT STATED IN ITEM 15a HAS BEEN FULLY PAID ON..........................................................................................................

F.1.1.32.18
F. REQUEST REQUEST FOR THE AMOUNT STATED IN ITEM 15b TO BE:

REFUNDED OFFSET AGAINST TAX PAYABLES

G. ART. 25 ART. 25 INSTALLMENT FOR THE FOLLOWING YEAR..........................…….……. Rp.

INSTALLMENT
FOR THE THE AMOUNT IS CALCULATED BASED ON :
FOLLOWING
YEAR a. 1/12 OF AMOUNT STATED IN ITEM 13 a

b. SEPARATE CALCULATION IS ATTACHED

H. INCOME SUBJECT TYPE OF INCOME TAX BASE / GROSS INCOME TAX

TO FINAL TAX (RUPIAH) (RUPIAH)
AND SUBJECT TO
SEPARATE TAX SUBJECT TO FINAL TAX

a. INTEREST ON TIME AND SAVING DEPOSITS..................................

b. INTEREST/DISCOUNT ON BONDS SOLD IN STOCK EXCHANGE AND
DISCOUNTS ON BANK INDONESIA CERTIFICATE (SBI) ....
c. SALE VALUE OF SHARES SOLD IN STOCK EXCHANGE …..……
d. LOTTERY PRIZES ……………………………………………………..
e. LUMPSUM PAYMENT OF SEVERANCE, OLD AGE ALLOWANCE AND
PENSION ..........................…………………….….……..……….
f. HONORARIUM PAID FROM STATE / REGIONAL BUDGET …...
g. TRANSFER VALUE OF LAND AND OR BUILDING .............……...
h. VALUE OF BUILDING RECEIVED FOR BUILD OPERATE TRANSFER
(BOT) ...........…………………………………...………....
i. RENTAL OF LAND AND/OR BUILDING …………………………....

j. OTHER INCOME SUBJECT TO FINAL TAX ..…………………...…

SUBJECT TO SEPARATE TAX

a. WIFE’S INCOME FROM ONE EMPLOYER .....................……..…….

b. SON’S/DAUGHTER’S INCOME FROM WORK …..………………….

TOTAL…… …......
I. NON TAXABLE GROSS INCOME
OBJECTS
(RUPIAH)

a. AID / DONATION / BESTOWED……..............................................................................................

b. INHERITANCE....................................................................................................................................

c. PROFITS DISTRIBUTION FROM LIMITED PARTNERSIPS, PARTNERSHIPS, GROUPS, FIRMS,

JOINT COMPANIES………………………………………................................................................
d. CLAIM OF HEALTH, ACCIDENT, LIFE, DUAL FUNCTION INSURANCE, SCHOLARSHIP...

e. OTHER NON TAXABLE INCOME……………………………………...........................................

TOTAL ……..............

J. ASSETS AND 1. TOTAL ASSETS [BROUGHT FORWARD FROM ATTACHMENT II OF FORM 1770 S PART A TOTAL COLUMN (4)]
LIABILITIES Rp.........................

2. TOTAL LIABILITIES [BROUGHT FORWARD FROM ATTACHMENT II OF FORM 1770 S PART B TOTAL COLUMN (4)]
Rp........................

K. ATTACHMENTS IN ADDITION TO ATTACHMENTS TO FORM 1770-S, THE FOLLOWING ARE ATTACHED:

a. COPY OF FORM 1721-A1 AND/OR 1721-A2

b. LIST OF DEPENDENT FAMILY MEMBERS

c. 3RD COPY OF ART. 29 INCOME TAX PAYMENT FORM

d. LIMITED POWER OF ATTORNEY (IF SO ASSIGNED)

e. ………………………………………………………..

L. STATEMENT I AM AWARE OF ALL THE CONSEQUENCES INCLUDING THE PENALTIES PER THE PREVAILING LAWS AND I HEREBY STATE
THAT ALL INFORMATION AND ATTACHMENTS CONTAINED HEREIN ARE CORRECT, COMPLETE AND CLEAR.

…………………………, ………………………………..200 ……
TAX PAYER SIGNATURE :

PROXY FULL NAME :

F.1.1.32.18