"KEMENTERIAN KEUANGAN REPUBLIKINDONESIA
DIREKTORAT JENDERAL PAJAK
FORMULIR PERMOHONAN EFIN
1S es PT ACETAR ANDEAN ANON PADA OL AN YG ESA
war Pain onan PIBAnt ADAN ENDAARA
yensspenuovonax —— [Jaxrvast Cleenccawran FJoeraxuanc
A:DENTITAS WAJIBPAAK
Now 02.330. 90.5-493,000 EAN
Naw aca Wslaie Uatadt
TEMPATLAHIR ‘TANGCALLATIR 2 Oweper yy
Wancawecara INDONESIA NIK warms 40002
SNEGARA Wwrovesia
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[BL IDENTITAS WAKIL WAIIB PAJAK / PE|ABAT ATAU PIHAK YANG DI TUNJUK SEBAGAI PENDAHARA
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D. TELEPONDANALAMAT EMAIL
(om TELEFON DAN EMAIL SEBAGAL SAA OMNIS ALAM RAMA PELAMSALULAN LDA KEWABBA PED AUAAN MELA LAYANANPAMK ONLINE)
‘TELEPON SELULER 2 OP gLEgN :
ALAMAT EMAL, £ Reeqeeain@ gout cor
E PERNYATAAN
Dengan ni, saya mengajukan permehonan akivasi EFI dan mendafarkan alamatemal srt nomortelepon yang digunakan sebaga
saranakomunilas dalam rangla plaisansan hak an kewajisaa melalui Layanan Pak Online erkenaan dengan permohonan di
tax menyatakan dengan sesungguhnya baw sya
1 telah mengisdatadiatas dengan benar dan lengkap:
2. slap unukmelakukan trims lelronik dengan DirelcurJenderalPajakterkaitpelaksanaan hak dan kewaliban
perpajakan;
3 menjamin nomortlepon dan alamat surat eleltonikyang didafarkan etap aki,
4 akan menjagakershasiaan dan keamanan Sertifkat Elektronik PIN ten, username dan password daa bertanggung awa
enub akan segalakeruglan dan atau konsekuens! hum apalslamelanggarkerahasiaan terse dan
5 menyadar sepenuhnya akan hak kewajban, dan sgalaaibt penyapaian SPT Elelronikmelalulslurantertenty yong
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