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FORM

ANNUAL
INDIVIDUAL
INCOME TAX RETURN

1770
TAX YEAR :

COMPLETE USING BLOCK / TYPED LETTERS


MARK X IN APPROPRIATE

FINANCE DEPARTMENT OF RI
DIREKTORATE GENERAL OF TAX

(BOX)

COMPLETE CORRECTLY, COMPLETELY AND CLEARLY

MO

YR

MO

YR

to

ACCORDING TO THE GUIDELINES

TAX ID (N P W P)
:
NAME OF TAXPAYER

...

RESIDENTIAL ADDRESS

...

CITY / POST CODE

TYPE OF BUSINESS / INDEPENDENT


WORK ACTIVITY

. KLU

BUSINESS TRADE NAME

...

BUSINESS / WORK ADDRESS

...

TELEPHONE / FAX

....................................

...

A.

NET INCOME CALCULATION :

NORM

BOOKKEEPING
RUPIAH

B.

C.

NET INCOME

TAXABLE
INCOME

1.

DOMESTIC NET INCOME FROM BUSINESS OR INDEPENDENT WORK ACTIVITIES


[BROUGHT FORWARD FROM FORM 1770 I PART A NO. 4 COLUMN (3) OR FORM
1770-I PART B TOTAL COLUMN (5)] ......................................................................................

2.

DOMESTIC NET INCOME FROM EMPLOYMENT [BROUGHT FORWARD FROM FORM


1770 - I PART C TOTAL COLUMN (5)] .....................................................................................

3.

OTHER DOMESTIC NET INCOME [BROUGHT FORWARD FROM FORM 1770 I PART
D TOTAL COLUMN
(5)] ..................................................................................................................

4.

OFFSHORE NET INCOME [BROUGHT FORWARD FROM FORM 1770 - II PART B


TOTAL COLUMN
(4)] ................................................................................................................................

5.

TOTAL NET INCOME (1 S.D. 4) ................................................................................................

6.

TITHE........................................ .....................................................................................................

7.

NET INCOME AFTER DEDUCTION OF TITHE (5


6) ........................................................................................................................................................
.

8.

LOSS COMPENSATION..... .........................................................................................................

9.

NET INCOME AFTER LOSS COMPENSATION (7 8) ...........................................................

10.

NON TAXABLE INCOME............................................................................................................


S / .....

D.

E.

INCOME TAX
PAYABLE

TAX CREDIT

M / .....

M / W / .....

ASSET SPLIT
/ .....

LIVING
APART / .....

11.

TAXABLE INCOME (9 10) .......................................................................................................

12.

INCOME TAX PAYABLE ( RATES PER ART. 17 OF INCOME TAX LAW x LETTER C NO.
11 ) ..................................................................................................................................................

13.

REFUND / DEDUCTION OF ART. 24 (OFFSHORE TAX CREDIT)WHICH HAS BEEN


CREDITED............................................................................................................................ ........

14.

TOTAL INCOME TAX PAYABLE (12 + 13) ..............................................................................

15.

INCOME TAX WITHHELD/COLLECTED BY OTHER PARTIES/BORNE BY GOV'T AND


PAID/WITHHELD/PAYABLE OVERSEAS (BROUGHT FORWARD FROM FORM 1770- II
PART A AND PART B)..................................................................................................................

16.

a.

INCOME TAX PAYABLE BY SELF


--------------------------------------------------------------------

b.
17.

(14 15) ..............................................

OVERWITHHELD/OVERCOLLECTED TAX

TAX PAID BY SELF


a. ART. 25 (1) INCOME TAX .....................................................................................................
b ART 25 (7) INCOME TAX..........................................................................................................
c ART. 25 TAX COLLECTION NOTICE (PRINCIPAL).............................................................
d. FISCAL EXIT TAX...............................................................................................................
TOTAL (a + b + c + d ) .................................................................................................................

F.1.1.32.16

F.

UNDER/OVER
PAYMENT OF
TAX

18.

a.

UNDERPAYMENT OF TAX (ART. 29 INCOME TAX)

----------------------------------------------------------------------------------- (16
17) ...........
b.

OVERPAYMENT OF TAX (ART. 28A INCOME TAX)

AMOUNT STATED IN ITEM 18a HAS BEEN FULLY PAID ON


G.

REQUEST

REQUEST FOR THE AMOUNT STATED IN ITEM 18b TO BE


REFUNDED

OFFSET AGAINST TAX PAYABLES

H.

I.

J.

K.

ART. 25
INSTALLMENT
FOR THE
FOLLOWING
YEAR

INCOME
SUBJECT TO
FINAL TAX,
INCOME OF
CERTAIN
ENTREPRENEURS AND
NON TAX
OBJECTS

ASSETS AND
LIABILITIES

ATTACHMENTS

Rp

ART. 25 INSTALLMENT FOR THE FOLLOWING YEAR ............................................................


THE AMOUNT IS CALCULATED BASED ON :
a.

1/12 OF AMOUNT STATED IN ITEM 16a

b.

SEPARATE CALCULATION IS ATTACHED


TAX BASE / GROSS INCOME
(RUPIAH)

TAX
(RUPIAH)

(1)

a.

AMOUNT SUBJECT TO FINAL TAX AND AMOUNT


SUBJECT TO SEPARATE TAX [BROUGHT FORWARD
FROM FORM 1770-III TOTAL OF PART A I AND II COLUMN
(4)]................................................................................

b.

INCOME OF CERTAIN ENTREPRENEURS [BROUGHT


FORWARD FROM FORM 1770-III PART A III COLUMN (3)
AND (4)] ......

c.

NON TAX OBJECTS [BROUGHT FORWARD FROM FORM


1770
III
TOTAL
OF
PART
B
COLUMN
(3)] ..................................................................................

(2)

1. TOTAL ASSETS [BROUGHT FORWARD FROM FORM 1770-IV PART A TOTAL OF


COLUMN (4) ]

Rp ........

2. TOTAL LIABILITIES [BROUGHT FORWARD FROM FORM 1770-IV PART B TOTAL OF


COLUMN (4) ]

Rp ....

IN ADDITION TO ATTACHMENTS 1770-I TO 1770-III, THE FOLLOWING ARE ATTACHED :


a.

BALANCE SHEETS AND INCOME STATEMENTS, OR


RECAPITULATION OF MONTHLY REVENUE / GROSS RECEIPTS (DELETE AS NECESSARY)

L.

STATEMENT

b.

COPY OF FORM 1721-A1 AND/OR 1721-A2 (.......... PAGES)

c.

3RD COPY OF ART. 29 INCOME TAX PAYMENT FORM

d.

LIMITED POWER OF ATTORNEY (IF SO ASSIGNED)

e.

ART. 25 INSTALLMENT CALCULATION FOR THE FOLLOWING YEAR

f.

INCOME TAX PAYABLE CALCULATION FOR TAX PAYER WITH ASSET SPLIT

g.

EVIDENCE OF TAX WITHHOLDING/COLLECTION BY OTHER PARTIES / BORNE BY THE GOVERNMENT AND


PAID/WITHHELD OVERSEAS

h.

LIST OF DEPENDENT FAMILY MEMBERS

i.

......................................................................................................................................................................................

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.
,

F.1.1.32.16

TAXPAYER

SIGNATURE

PROXY

FULL NAME

..200