PEMERINTAH PROVINSI JAWA TENGAH

DINAS KESEHATAN
Jl. Piere Tendean No. 24,Telp. (024) 3511351 (Hunting),Fax. (024) 3517463,
3582886 Website: dinkesjatengprov.go.id, E-mail:mi_jateng@yahoo.co.id,
gfaids.ssfjateng@gmail.com Semarang 50131

Semarang, 07 Februari 2020

Bank Mandiri KC Pemuda Semarang

Jl. Pemuda No 73 Semarang

Attention to : Head of Branch

Dear Sir,

BANK CONFIRMATION REQUEST

INDONESIA HIV RESPONSE : ELIMINATING THE AIDS EPIDEMIC IN INDONESIA
BY 2030
We would appreciate if you could provide for audit purposes the information requested in the attached
forms.

It is imperative that you fill out the forms completely. If a certain item is not applicable please state “ Nil”.
You must use these forms, a reply in any other format will be accepted by our auditors if the required
information are answered completely. You must also return the originals of the completed forms to
our auditors. A faxed/e-mail copy is also not acceptable.

To facilitate the timely completion of the audit, it would be appreciated if the forms were completed and
returned by Feb 23, 2020 (5 Hari setelah pengiriman).

Please mail the original of the completed form(s) direct to our auditors:

KAP Amir Abadi Jusuf, Aryanto, Mawar & Rekan

RSM Indonesia
Member Firm of RSM International
Plaza ASIA 10th Floor, Jl. Jend. Sudirman Kav. 59, Jakarta Selatan 12190 – Indonesia
Attention to Mrs. Ita Christine (Fax No. +62-21 51401350)

Addressed envelopes are enclosed for this purpose.

Yours faithfully,

Dr. Tatik Murhayati, M.Kes

Program Manager GF AIDS SR Jateng

BANK CONFIRMATION REQUEST

BANK CONFIRMATION - AUDIT REQUEST BANK / CLIENT / AUDITOR’S FILE

CONFIRMATION DATE __/ __/____

Instructions
Auditor
(a) Complete the first shaded areas before forwarding to the bank.
Bank
(a) Ensure that the details supplied are as at the confirmation date shown below.
(b) Complete all known details in the shaded areas, by listing information as called for under the
relevant heading, from detail contained in the bank's records.
(c) Confirm details in the shaded areas as to correctness. If a certain item is not applicable please
state “Nil”.
(d) The form should be received by the bank. All completed copies of the Confirmation are to be
signed with original returned direct to the auditor in the enclosed stamped addressed envelope.

To From

Bank Mandiri KC Pemuda INDONESIA HIV RESPONSE : ELIMINATING

Jl. Pemuda No 73 Semarang THE AIDS EPIDEMIC IN INDONESIA BY 2030
Jalan Percetakan Negara No. 29
Gedung B Lt. 3
Dirjen P2PL – Dep. Kesehatan
Johar Baru Jakarta 10560

Auditor Customer's Authorised Signature

KAP Amir Abadi Jusuf, Aryanto, Mawar & Rekan,

RSM Indonesia
Registered Public Accountant
Plaza ASIA 10th Floor,
Jl. Jend. Sudirman Kav. 59, Jakarta Selatan 12190
– Indonesia
Attention to : Mrs. Ita Christine Dr. Tatik Murhayati, M.Kes
Faximile No. : +62-21 51401350 Program Manager GF AIDS SR Jateng

Confirmation Date ___/___/___

1. CREDIT ACCOUNT BALANCES

Give details of all account balances in favour of the bank customer as at 31/12/2019. Include details of
any current accounts, interest/non-interest bearing deposits, foreign currency accounts,
convertible/negotiable certificates of deposit, money market, etc, if not listed below.

Account Name Account Number Balance Currency Interest

Rate

2. DEBIT ACCOUNT BALANCES

BANK CONFIRMATION REQUEST

Give details of all account balances owed to the bank as at 31/12/2019 by the bank customer in respect
of overdraft accounts, bank loans, term loans etc and also repayment terms.
Account Account Balance Currency Overdraft Interest Repayment Term
Name Number Limit Rate (eg. Monthly,
quarterly etc)

3. BALANCES OF ACCOUNTS (DEPOSITS & ADVANCES), SECURITIES HELD

(a) Please confirm details of all account balances [indicating currency (CCY)] as at 31/12/2019.
Include details of: nostro accounts, vostro accounts, current accounts, interest/non-interest
bearing deposits, foreign currency accounts, convertible/negotiable certificates of deposit, money
market, etc, if not listed. Confirm details of any securities held for payment eg, Promissory Notes.
(b) Confirm details of direct liabilities (bank & term loans etc), indicating the collateral lodged by the
customer in respect to each outstanding loan. Details of repayment terms should also be
confirmed.

Account Account Balance CC Interest Interest Date Other Maturity Collateral

Name Number DR/CR Y Rate Accrued Paid Charges Date Lodged

4. PROMISSORY NOTES/BILLS OF EXCHANGE HELD FOR COLLECTION ON BEHALF OF THE

CUSTOMER
Maker/Acceptor Amount Due Date

5. CUSTOMER'S OTHER LIABILITIES TO THE BANK

List liabilities owed, including:
(a) Bills discounted with recourse, endorsed drafts/notes, forward exchange contracts, letters of
credit, liability in respect of shipping documents where customer's account not yet debited.
(b) Include date, name of beneficiary, amount and brief description of any guarantees, bonds or
indemnities undertaken by the bank on behalf of the customer (with recourse) or given by the
customer.
(c) Other liabilities - give details.

Nature of Liability Amount Currency Due Date

6. ITEMS HELD AS SECURITY FOR CUSTOMER'S LIABILITIES TO THE BANK

Indicate if securities relate to particular borrowings or liabilities to the bank and whether lodged in the

BANK CONFIRMATION REQUEST

customer's name. Also include details of any negative pledge arrangements. If lodged by a third party,
that party's authority to disclose details must be attached.
Description (include amount if applicable)

7. ACCOUNTS OPENED/CLOSED
List details of any accounts opened or closed during the twelve months prior to confirmation date
31/12/2019.

Accounts Opened Accounts Closed

Account Name Account Account Name Account
Number Number

8. UNUSED LIMITS/FACILITIES

Please confirm details of all available unused limits/facilities at confirmation date.

Types of Facility Amount of Facility Amount of Facility Condition of Facility

Unused Use

9. OTHER INFORMATION
Please confirm (see shaded area) and/or provide any other details (unshaded area) relating to any
financial relationships not dealt with under any of the above headings.

This certificate has been completed from our records at branch only. The Bank and
its staff are unable to warrant the correctness of that information and accordingly hereby disclaim all
liability in respect of the same. The information contained herein is confidential and provided for private
use in confirmation of our customer accounts for audit purposes only. It may not be used for any other
purpose or by any other persons. In particular this is not a credit reference.

Authorising Officer's Signature Name Bank Stamp Date Completed

and Returned

Title
Telephone No. ___/___/___

BANK CONFIRMATION REQUEST