PT.

ANDARAN TUA SEJATI

Jalan Rawa Jati Timur X No. 1.RT/RW 002/006. Kalibata – Pancoran, 12750
JAKARTA - INDONESIA

CLIENT INFORMATION SHEET – CIS

In accordance with Articles 2 through 5 of the Due Diligence Convention and the Federal
Banking Commission Circular of December 1998, and under the US Patriot Act of 2002, as amended
in February 2003 concerning the prevention of money laundering and 305 of the Swiss Criminal
Code, the following information may be supplied to banks and/or other financial institutions for
purposes of verification of identity and activities of the Client described below, and the nature
and origin of the funds which are to be utilized. The foregoing is subject to agreement by all
parties to whom this information is provided that they are obligated to respect the privacy
rights of the Client and all individuals described herein, as well as the generally accepted
professional standards relating to the maintenance of confidential information, and to take
all appropriate precautions to protect the confidentiality of the information contained herein,
This legal obligation shall remain in full force indefinitely without restriction.

I hereby submit the following information for your consideration. I understand that this
information will be relied upon, unconditionally, as statements by me of material fact.

CUSTUMER INFORMATION SHEET ( CIS ) :

No. INFORMATION QUIRY DETAIL

1 PROFIL

a). Represented By SRI SUTARTI

b). Nationality INDONESIA

c). Passport Number C0526714

d). Date Of Issue May, 17th, 2018

e). Date Of Expiration May, 17th, 2018

f). Date Of Birth December, 12 th, 1967.

g). Place Of Birth Bengkulu

h). Identity Card No. (KTP) 1708045212670007

i). Contact Address Jalan Rawa Jati Timur X No. 1.RT/RW 002/006. Kalibata –
Pancoran, 12750
 j). Contact Telp No.

k). Mobile Telp No. 081271847645

l). Email tuasejatiandaran@gmail.com

m). Occupation Businessman

n). Company Name PT. ANDARAN TUA SEJATI

o). Company Registration 4019042231241937

p). Office Address Jalan Rawa Jati Timur X No. 1.RT/RW 002/006. Kalibata –
Pancoran, 12750
q). Office Telp No

r). Office Fax No.

s). Email tuasejatiandaran@gmail.com

2. Address for Mail Jalan Rawa Jati Timur X No. 1.RT/RW 002/006. Kalibata –
Pancoran, 12750

3. Address for Courier Jalan Rawa Jati Timur X No. 1.RT/RW 002/006. Kalibata –
Pancoran, 12750

4. BANK COORDINATE

a). BANK NAME MANDIRI

b). Branch and Address KC Tangerang Gading Serpong Ruko Gading Serpong Blok AA4
No. 36-38 Jl. Boulevard Gading Serpong Tangerang 15810

c). Account Numbers 176 000 173 9224. IDR

d). Account Name PT. ANDARAN TUA SEJATI

e). Account signatory SRI SUTARTI

f). SWIFT Code BMRIIDJAXXX

g). Bank Officer Name Mr. Rudy S. Prawira Putra

h). Bank Telephone No. (021) 5462297

i). Bank Officer Email 15515@bankmandiri.co.id

 5. Affirmation

I hereby swear under the full penalty of perjury, that the information provided herein is
both true and accurate. I am in control of the assets stated bellow and have signatory
authority on the aforementioned bank account and have full authority to execute all
contracts and agreements relating to pleading the assets for a loan. The funds are in full
compliance with the anti-money laundering policies set forth by Financial Action Task Force
(FATF) 6/01.

Signed, December 14th, 2020

SIGNATORY

Name : SRI SUTARTI

Title : Commissioner
Passport Number : C0526714
Country of Issuance : Indonesia