Mohon cantumkan

logo perusahaan TRANSFER REQUEST / DEBIT NOTE

Ditujukan ke : Escrow team of PT Tokopedia

Yth. : Klismann
Alamat komersial : Tokopedia Tower, 30th Floor Jl. Prof. Dr. Satrio Kav. 11, Kel. Karet Semanggi, Kec. Setiabudi
Jakarta Selatan 12940
Alamat NPWP : Gedung Tokopedia Tower, Lantai 52 Jl. Prof. Dr. Satrio Kav. 11
RT 003 RW 003 Karet Semanggi Setiabudi Jakarta Selatan DKI Jakarta
NPWP : 21.089.397.0-035.000

Dengan mengacu pada kesepakatan kerjasama antara PT Tokopedia (Indonesia) dan [nama Mitra], kami [nama Mitra] ingin meminta PT
Tokopedia untuk mentransfer dana yang terkait dengan pembayaran dari Pengguna ("User") sebagaimana dimaksud dalam Perjanjian dengan
[nama Mitra] sebagai penerima manfaat, dengan rincian sebagai berikut:

Nama : [to be completed by Partner, re: full name of legal entity of Partner]
Alamat : [to be completed by Partner, re: full address of Partner]
[to be completed by Partner, re: full address of Partner]
Negara : [to be completed by Partner, re: Country's name]
Nomor telepon : [to be completed by Partner, re: phone number]
Alamat email : [to be completed by Partner, re: email]

Nomor Transfer Request / Debit Note : [to be completed by Partner, re: document's number determined by Partner]
Tanggal penerbitan : [to be completed by Partner, re: document's date determined by Partner]
Jatuh tempo : [to be completed by Partner, re: document's date determined by Partner]

Rincian:
No. Deskripsi Quantity / SKU Unit Price Jumlah (IDR or USD)*
1 Settlement Transaction DD-MM
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Total - - -

Nama Penerima : [please complete by Partner]

Bank : [please complete by Partner]
Nomor Rekening : [please complete by Partner]
Swift Code : [please complete by Partner]
Mata Uang : [please complete by Partner]

Disetujui oleh:
[Partner's name]

Materai
Rp 6.000,-

Nama:
Tanggal :