SPT PPH BDN 2009 English Ortax

CORPORATE ANNUAL TAXABLE YEAR
1771 INCOME TAX RETURN 2 0

FORM
ATTENTION h FOLLOW INSTRUCTION IN THE MANUAL

MINISTRY OF FINANCE h PRINT OR TYPE WITH CAPITAL LETTER OR BLACK INK
DIRECTORATE GENERAL OF TAXES h MARK "X" IN THE APPROPRIATE BOX AMENDED RETURN
TIN :
TAXPAYER'S NAME :
IDENTITY
BUSINESS CLASIFICATION : KLU :

TELEPHONE NUMBER : - FACSIMILE NO. -
ACCOUNTING PERIOD : to
FOREIGN DOMICILE OF HEAD OFFICE (Permanent Establisment only) :
FINANCIAL STATEMENT : AUDITED AUDIT OPINION UNAUDITED
NAME OF PUBLIC ACCOUNTANT FIRM :

TIN OF PUBLIC ACCOUNTANT FIRM :
NAME OF CPA :
TIN OF CPA :
NAME OF TAX CONSULTANT FIRM :
TIN OF TAX CONSULTANT FIRM :
NAME OF TAX CONSULTANT :
TIN OF TAX CONSULTANT :
*) The filling of coloumns of Rupiahs must be without decimal value (see example in the manual book page.3) IDR *)
(1) (2) (3)
A. TAXABLE INCOME
1. FISCAL NET INCOME

1
(Copy from Form 1771-1 line 8 column 3)…………………………………..
2. FISCAL LOSS CARRIED FORWARD

2
(Copy from Special Attachment 2A Total of Column B) …………………..
3. TAXABLE INCOME (1 - 2) ……………………………………………………… 3
4. INCOME TAX DUE (Choose one of these Rates according to Taxpayer criteria. See manual book)
a. Tax Rate Article 17 paragraph (1) letter b X line 3) …………

B. INCOME TAX DUE
b. Tax Rate Article 17 paragraph (2b) X line 3…………………. 4
c. Tax Rate Article 31E paragraph (1)

5. ADJUSTMENT FOR FOREIGN TAX CREDIT REFUNDED THAT HAD
5
BEEN CREDITED IN THE PREVIOUS YEAR'S RETURN
(Income Tax Art.24)
6. TOTAL TAX DUE (4 + 5) ………………………………………………………… 6
7. INCOME TAX BORNE BY THE GOVERNMENT (Foreign Aid Project) 7
8. a. DOMESTIC TAX CREDIT

8a
(Copy from Form 1771-III Total of Column 5)
b. FOREIGN TAX CREDIT
8b
(Copy from Special Attachment 7A Total of column 7)
c. TOTAL (8a + 8b) ……………………………………………………………….8c

C. TAX CREDITS
9. a. TAX DUE AFTER CREDIT

(6 - 7 - 8c) 9
b. TAX OVERLY WITHHELD
10. PREPAID TAX :

10a
a. MONTHLY INSTALLMENT TAX ARTICLE 25………………………………
b. NOTICE OF TAX COLLECTION (Principal only) 10b
c. TAX ARTICLE POINT 8 / DEPARTURE TAX ………………………………10c
d. TOTAL (10a + 10b + 10c) ……………………………….. 10d
11. a. UNDERPAID TAX (INCOME TAX ARTICLE 29)

D. INCOME TAX UNDER/OVER
(9 - 10d) 11
b. OVERPAID TAX (INCOME TAX ARTICLE 28A)
12. UNDERPAID TAX ON NUMBER 11.a SETTLED ON…………………………………………………

PAID
TGL BLN THN

13. OVERPAID AMOUNT STATED IN 11.b WOULD BE :
a. REFUNDED b. COMPENSATED WITH OUTSTANDING TAX PAYABLE
Refund for a Taxpayer with Certain Criteria only : Preliminary Refund (Tax Law on Article 17C or 17D)
F.1.1.32.14
FORM 1771 Page 2
IDR
(1) (2) (3)
E. MONTHLY INSTALLMENT OF ART.25 FOR CURRENT YEAR
14. a. INCOME BASE FOR CALCULATION OF MONTHLY TAX

14a
INSTALLMENT ……………………………………………………..
b. FISCALL LOSS CARRIED FORWARD :
14b
(From Special Attachment 2A Total of Column 9)
14c
c. TAXABLE INCOME (14a - 14b) ……………………………………………
d. TAX DUE
14d
(Tax Rate from Part B line 4 X 14c) ………………………………………….
e. WITHOLDING TAX PAID BASED ON NUMBER 14a

14e
14f
f. INCOME TAX MUST BE PAID (14d - 14e) ……………………….
14g
g. INCOME TAX ARTICLE 25 : (1/12 x 14f) …………………………
F.FINAL TAX AND NON-
15. a. FINAL TAX :

TAXABLE INCOME
15a
(From Form 1771-IV Total Part A Column 5) ……………………………
b. NON-TAXABLE INCOME :
GROSS INCOME
15b
(From Form 1771-IV Total Part B of Column 3) ……………………………
RELATED PARTIES
G. STATEMENT OF
TRANSACTION IN
16. a. There is a Transaction in Related Parties and/or with Tax Haven Country Resident
(Compulsory to submit Special Attachment 3A, 3A-1. and 3A-2 Manual Book of Annual Return)*
b. There is not a Transaction in Related Parties and/or with Tax Heaven Country Resident.
17. OTHER THAN FORM OF 1771-I, 1771-II, 1771-III, 1771-IV, 1771-V, AND 1771-VI
WITH THIS ALSO ATTACHED :
a. THIRD COPY OF TAX PAYMENT RECEIPT OF INCOME TAX ARTICLE 29
b. FINANCIAL STATEMENTS
c. TRANSCRIPT OF ELEMENTS FROM FINANCIAL STATEMENT (Special Attachment 8A-1 /8A-2 /8A-3 /8A-4 /8A-5 /8A-6)*
d. DEPRECIATION AND AMORTIZATION TABLES (Special Attachment 1A of the Annual Income Tax Return Manual)*
e. CALCULATION OF FISCAL LOSS CARRIED FORWARD (Special Attachment 2A of Income Tax Return Manual)*
H. ATTACHMENTS
f. INVESTMENT FACILITIES PROVIDED (Special Attachment 4A of the Income Tax Return Manual)
g. LIST OF MAJOR BRANCHES (Special Attachment 5A of the Income Tax Return Manual)
h. THIRD COPY OF PAYMENT RECEIPT OF INCOME TAX ARTICLE 26 PARAGRAPH (4) (For Permanent Establishment only)
i. CALCULATION OF INCOME TAX ART.26 PARAGRAPH (4) (Permanent Establishment only) (Special Attachment 6A of Income Tax Return Manual)*
j. FOREIGN TAX CREDITS (Special Attachment 7A Income Tax Return Manual)*
k. POWER OF ATTORNEY (if needed)
l. ……………………………………………………………………………………………………………………..
m. ………………………………………………………………………………………………………………………
n. ………………………………………………………………………………………………………………………
DECLARATION
Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including
All Attachments Provided, are True, Complete, Clear, and Under No Circumstances Wharsoever.
a. TAX PAYER b. AUTHORIZED c. d.

REPRESENTATIVE (place) date month year
SIGNATURE AND COMPANY SEAL
FULL NAME MANAGEMENT/ : e.
REPRESENTATI VE
TIN : f.
F.1.1.32.14
ATTACHMENT-I
1771 - I
TAXABLE YEAR
FORM
CORPORATE ANNUAL INCOME TAX RETURN

MINISTRY OF FINANCE 2 0
DIRECTORATE GENERAL OF TAXES CALCULATION OF FISCAL NET INCOME
TIN :
IDENTITY
TAXPAYER'S NAME :
NO DESCRIPTIONS IDR
(1) (2) (3)
1. DOMESTIC COMMERCIAL NET INCOME :
1a
a. GROSS INCOME ……………………………………………………………………… .
1b
b. COST OF GOOD SOLD …………………………………………………………… .
1c
c. OTHER EXPENSE …………………………………………………………………… .
1d
d. NET INCOME FROM BUSINESS (1a - 1b - 1c) ………………………… .
1e
e. INCOME FROM SIDE BUSINESS ……………………………………………… .
1f
f. EXPENSE FROM SIDE BUSINESS ………………………………………… .
1g
g. NET INCOME FROM SIDE BUSINESS (1e - 1f) ……………………… .
1h
h. TOTAL (1d + 1g) …………………………………………………………………… .
2. FOREIGN COMMERCIAL NET INCOME 2

(From Special Attachment 7A Column 4)……………………………………………….. .
3. TOTAL OF COMMERCIAL NET INCOME (1h + 2) ……………………………………… . 3
4. INCOME SUBJECT TO FINAL TAX

4
AND NON-TAXABLE INCOME………………………………………………………….. .
5. POSITIVE FISCAL ADJUSTMENT :

a. EXPENSE CHARGED OR INCURRED FOR THE PERSONAL BENEFIT OF
5a
SHAREHOLDERS, PARTNERSHIP OR MEMBERS... …………………………… .
5b
b. FORMATION OR ACCUMULATION OF ALLOWANCES ……………………….. .
c. CONSIDERATION OR REMUNERATION RELATED TO EMPLOYMENT OR
5c
SERVICES GIVEN IN THE FORM OF A BENEFIT IN KIND………………………….
d. EXCESSIVE COMPENSATION PAID TO SHAREHOLDERS OR OTHER

5d
ASSOCIATED PARTIES AS A CONSIDERATION OF WORK PERFOMED…… .
5e
e. GIFTS, AIDS, OR DONATION ………………………………………… .
5f
f. INCOME TAX …………………………………………………………………………… .
g. SALARIES PAID TO A MEMBER OF AN ASSOCIATION, FIRMA, OR LIMITED
5g
PARTNERSHIP WHICH CAPTAL DOES NOT CONSIST OF STOCKS………… .
5h
h. ADMINISTRATION SANCTION ………………………………………………… .
5i
i. LESS COMMERCIAL DEPRECIATION OVER FISCAL DEPRECIATION .
5j
j. LESS COMMERCIAL AMORTIZATION OVER FISCAL AMORTIZATION .
5k
k. DEFERRED EXPENSES ………………………………………………………………...
5l
l. OTHER POSITIVE FISCAL ADJUSTMENTS ……………………………………… .
5m
m. TOTAL 5a s.d. 5l ……………………………………………………………………… .
6. NEGATIVE FISCAL ADJUSTMENT :
6a
a. LESS COMMERCIAL DEPRECIATION UNDER FISCAL DEPRE .
6b
b. ESS COMMERCIAL AMORTIZATION UNDER FISCAL AMORTIZATION .
6c
c. DEFERRED INCOME ………………………………………………………………… .
6d
d. OTHER NEGATIVE FISCAL ADJUSTMENTS ……………………………………… .
6e
e. TOTAL 6a s.d. 6d …………………………………………………………………… .
7. FACILITIES OF INVESTMENT ALLOWANCES

7b
…… YEAR 7a (From Special Attachment 4A line 5b) …………………… .
8
8. FISCAL NET INCOME (3 - 4 + 5m - 6e - 7b) …………………………………………. .
NOTES : Copy Total of Line 8 to Form 1771 Letter A Line 1.
D.1.1.32.31
ATTACHMENT-II
1771 - II
TAXABLE YEAR
FORM

DIRECTORATE GENERAL OF TAXES DETAILS OF COST OF GOOD SOLD, OTHER OPERATING EXPENSE AND COMMERCIAL NON-OPERATING EXPENSE
IDENTITY
TIN : TAXPAYER'S NAME :
ACCOUNTING PERIOD : s.d.
NO DETAILS COST OF GOOD SOLD (IDR) OTHER OPERATING EXPENSE (IDR) NON-OPERATING EXPENSE (IDR) TOTAL (IDR)
(1) (2) (3) (4) (5) (6) = (3) + (4) + (5)
1. PURCHASE OF MATERIAL/MERCHANDISE
SALARIES, WAGES, BONUSES,

2. GRATIFICATION, HONORARIUM, AND
OTHERS
3. TRANSPORTATION EXPENSE
DEPRECIATION AND AMORTIZATION

4.
EXPENSE
5. RENT EXPENSES
6. INTEREST EXPENSES
7. EXPENSE RELATED TO SERVICE
8. BAD DEBT EXPENSE
9. ROYALTIES EXPENSE
10. MARKETING AND PROMOTION EXPENSE
11. OTHER EXPENSES
12. BEGINNING INVENTORY
13. ENDING INVENTORY (-/-)
14. TOTAL OF LINE 1 TO 12 MINUS LINE 13
Note :
h Number 1 for Trading Company fill with Inventory, for industry fill with purchase of material, indirect material and finished good.
h Number 7 includes management fee, technical assistance fee, and other services.
h Line 11 includes total expenses not covered in Line 1 to 10.
h Line 12 and 13 for tradingcompanies, filled with beginning/ending balances of merchandise inventory, for industrial companies, filled with beginning/ending balances of raw materials,
indirect materials, work in process, and finished goods inventory.
D.1.1.32.54
ATTACHMENT- III
1771 - III
TAXABLE YEAR
FORM

DIRECTORATE GENERAL OF TAXES FOREIGN TAX CREDIT
IDENTITY
WITHHOLDING OBJECT WITHHOLDING RECEIPT/TAX PAYMENT SLIP (SSP)/SSPCP

NO NAME AND TIN WITHHOLDING AGENT TYPES OF INCOME TAX WITHHELD (IDR)
(IDR) NUMBER DATE
INCOME/TRANSACTION
(1) (2) (3) (4) (5) (6) (7)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
dst
TOTAL TTL
Notes :
h Filled with calculation of each Withholding Tax Receipt. Page - from page Attachment-III
h Copy of Total Income Tax Article 22, Income Tax Article 23 and Income Tax Article 26 column (5) to Form 1771 Letter C Line 8.a.
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED
D.1.1.32.32
ATTACHMENT - IV
1771 - IV
TAXABLE YEAR
FORM

DIRECTORATE GENERAL OF TAXES FINAL INCOME TAX AND NON-TAXABLE INCOME
TIN :
IDENTITY
TAXPAYER'S NAME :
PART A : FINAL INCOME TAX
NO TYPES OF INCOME TAX BASE (IDR) RATE (%) INCOME TAX PAYABLE (IDR)
(1) (2) (3) (4) (5)

INTEREST INCOME ON TIME
DEPOSITS/OTHER SAVINGS AND DISCOUNT
1. OF CENTRAL BANK'S
SERTIFICATE/SECURITIES STATE
2. INTEREST/DISCOUNT OF BOND
3. INCOME FROM SALES VALUES OF SHARE

TRADED IN STOCK EXCHANGE
4. INCOME FROM SALES VALUE OF VENTURE

CAPITAL SHARE
INCOME FROM
5. DISTRIBUTOR/DEALER/AGENT OF OIL
PRODUCTS
6. INCOME FROM TRANSFER VALUE OF RIGHT

ON LAND/BUILDING
7. INCOME FROM LEASE/RENT VALUE OF

LAND/BUILDING
8. CONSTRUCTION RELATED FEE :
a. CONTRUCTOR
b. DESIGNER
c. CONSTRUCTION SUPERVISOR
GROSS SALES OF REPRESENTATIVE

9.
OFFICE
GROSS INCOME OF FOREIGN

10.
SHIPPING/AIRLINES COMPANY
GROSS INCOME OF DOMESTIC SHIPPING
11.
COMPANY
12. REVALUATION OF FIXED ASSETS\
DERIVATIVE TRANSACTION TRADE IN

13.
CAPITAL MARKET
14.
etc
TOTAL PART A TPA
Copy of Form 1771 letter F line 15 point a

PART B : NON-TAXABLE INCOME
NO TYPES OF INCOME GROSS INCOME (IDR)
(1) (2) (3)
1. AID/DONATION
2. GRANT
3. DIVIDEND FROM INVESTMENT/OWNERSHIP OF SHARES OF THE INDONESI

BUSINESS ENTITIES (Article 4 Paragraph (3) Item f of Income Tax Law)
4. CONTRIBUTION AND SPECIFIC INCOME RECEIVED BY A PENSION FUND
5.
SHARES OF PROFIT RECEIVED BY VENTURE CAPITAL COMPANIES FROM
ITS PARTNERS
6. EXCESS INCOME RECEIVED BY NONPROFIT AND REGISTERED
EDUCATION INSTITUTION OR RESEARCH AND DEVELOPMENT
ESTABLISHMENT WHICH ARE REINVESTED IN THE FORM OF FACILITIES
AND IN INFRASTRUCTURE FOR EDUCATIONAL AND/OR R&D ACTIVITIES
7.
etc
TOTAL PART B TPB
Copy to Form 1771 letter F line 15 point b

IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED Page - fro page Attachment-IV
D.1.1.32.34
ATTACHMENT - V
1771 - V
TAXABLE YEAR
FORM

MINISTRY OF FINANCE h LIST OF SHAREHOLDERS/CAPITAL OWNERS AND TOTAL DIVIDENDS DISTRIBUTED 2 0
DIRECTORATE GENERAL OF TAXESh LIST OF DIRECTORS AND COMMISSIONERS
TIN :
IDENTITY
TAXPAYER'S NAME :
PART A : LIST OF SHAREHOLDERS/CAPITAL OWNERS AND TOTAL DIVIDENDS DISTRIBUTED

TOTAL PAID IN SHARES
NO NAME AND ADDRESS TIN DIVIDEND (IDR)
(IDR) %
(1) (2) (3) (4) (5) (6)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
dst
TOTAL PART A TPA 100%
PART B : LIST OF DIRECTORS AND COMMISSIONERS
NO NAME AND ADDRESS TIN POSITION
(1) (2) (3) (4)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
dst
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED Page - fro page Attachment-V

D.1.1.32.35
ATTACHMENT - VI
1771 - VI
TAXABLE YEAR
2 0
FORM
MINISTRY OF FINANCE h LIST OF CAPITAL CONTRIBUTION IN AFFILIATION COMPANIES

DIRECTORATE GENERAL OF TAXESh LIST OF ACCOUNT PAYABLE FROM SHAREHOLDERS AND/OR AFFILIATION COMPANIES
h LIST OF ACCOUNT RECEIVABLE TO SHAREHOLDERS AND/OR AFFILIATION COMPANIES
TIN :
IDENTITY
TAXPAYER'S NAME :
PART A : LIST OF CAPITAL CONTRIBUTION IN AFFILIATION COMPANIES

AMOUNT OF CAPITAL CONTRIBUTION
NO NAME AND ADDRESS TIN
(IDR) %
(1) (2) (3) (4) (5)
1.
2.
3.
4.
5.
etc
TOTAL TTL
PART B : LIST OF ACCOUNT PAYABLE FROM SHAREHOLDERS AND/OR AFFILIATION COMPANIES

INTEREST/
NO NAME AND ADDRESS TIN TOTAL LOAN (IDR) YEAR YR %
(1) (2) (3) (4) (5) (6)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12
etc
PART C : LIST OF ACCOUNT RECEIVABLE TO SHAREHOLDERS AND/OR AFFILIATION COMPANIES

INTEREST/
NO NAME AND ADDRESS TIN TOTAL LOAN (IDR) YEAR YR %
(1) (2) (3) (4) (5) (6)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12
dst
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED Page - fro page Attachment-VI

D.1.1.32.36
SPECIAL ATTACHMENT 1A
FOR TAXABLE YEAR 2 0
LIST OF FISCAL DEPRECIATION AND AMORTIZATION
MONTH/ COST OF DEPRECIATION/AMORTIZATION FISCAL DEPRECIATION/AMORTIZATION

BEGINNING BALANCE
GROUP / TYPES OF ASSETS YEAR OF ACQUISITION METHOD IN CURRENT YEAR NOTE
ACQUISITION (IDR) (IDR) COMMERCIAL VALUE FISCAL (IDR)
TANGIBLE ASSETS
Group 1 :
………………………………………………….
Group 2 :
………………………………………………….
Group 3 :
………………………………………………….
Group 4 :
………………………………………………….
BUILDINGS
Permanent :
………………………………………………….
Not Permanent :
………………………………………………….
TOTAL DEPRECIATION (For Tax Purpose)……………..……………..……………..……………..……………..……………..……………..……………..……………..……………..…………………………………
TOTAL COMMERCIAL DEPRECIATION……………..……………..……………..……………..……………..……………..……………..……………..……………..………………….………………………….……
DIFFERENCE (COPY TO FORM 1771-I LINE 5 LETTER I OR LINE 6 LETTER a)……………..……………..……………..……………..……………….………………………..………………………..
INTANGIBLE ASSETS
Group 1 :
………………………………………………….
Group 2 :
………………………………………………….
Group 3 :
………………………………………………….
Group 4 :
………………………………………………….
Other Group
………………………………………………….
TOTAL AMORTIZATION (For Tax Purpose)……………..……………..……………..……………..……………..……………..……………..……………..………………………………...…..……………..……
TOTAL COMMERCIAL AMORTIZATION……………..……………..……………..……………..……………..……………..……………..……………..……………………….………………...……………..………
DIFFERENCE (COPY TO FORM 1771-I LINE 5 LETTER j OR LINE 6 LETTER b)……………..……………..……………..……………..……………….………………………..………………………..
…………………………………………..
TAXPAYER/AUTHORIZED REPRESENTATIVE
( ………………………………………………………….)
TAXABLE YEAR 2 0
FISCAL LOSS CARRIED FORWARD CALCULATION FOR TAX PURPOSE
FOR TAXABLE YEAR AND CURRENT TAXABLE YEAR
LOSS AND FISCAL NET INCOME KOMPENSASI KERUGIAN FISKAL
NO YEAR. YEAR. YEAR. YEAR. YEAR. YEAR.

YEAR IDR (CURRENT TAXABLE YEAR)
(THIS TAXABLE YEAR)
(IDR) (IDR) (IDR) (IDR)
IDR*) IDR**)
(1) (2) (3) (4) (5) (6) (7) (8) (9)
5
etc
TOTAL TTL
NOTE : ……………….,
*) COPY THE AMOUNT OF THISS COLUMN TO FORM 1771 LETTER A LINE 2
**) COPY THE AMOUNT OF THIS COLUMN TO FORM 1771 LETTER E LINE 14 POINT b TAXPAYER/AUTHORIZED REPRESENTATIVE
(…………………………………………..)
TAXABLE YEAR
STATEMENT OF TRANSACTION WITH RELATED PARTIES
TIN :
TAXPAYER'S :
I LIST OF RELATED PARTIES
No Name Address Tax Identification Number (TIN) Business Activities

Types of Relationship with Taxpayer
1 1 2 3 4
2 1 2 3 4
3 1 2 3 4
4 1 2 3 4
5 1 2 3 4
II DETAILS OF TRANSACTION WITH RELATED PARTIES
No Name Types of Transaction Transaction's Value Determination of Price Method shall be used Determination of Methods
1 a b c d e f g
2 a b c d e f g
3 a b c d e f g
4 a b c d e f g
5 a b c d e f g
………………………………,
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED TAXPAYER/AUTHORIZED REPRESENTATIVE
(………………………………………………)
SPECIAL ATTACHMENT 3A-1
TAXABLE YEAR
STATEMENT OF TRANSACTION IN RELATED PARTIES
TIN :
TAXPAYER'S NAME/PERMA :
I DOCUMENTATION OF ARM'S LENGTH TRANSACTION DETERMINATION
These are some particular notes that we made to support the fact that transactions that have been made with related parties are in accordance with the arm's length
principle and the common practice.
1 Concerning of Company's description in detail
That we have made note about :
Yes No
Ownership structure that refer to the dependability between all company in a one group of multinational company.
Organizational structure of Taxpayer Company
Operating aspects from Taxpayers business operations including details of functions which is delivered by units in the Taxpayers organization
Description of business environment in detail
2 Concerning of Transaction
Yes No
Transaction with related parties
Taxpayer's transaction with company which is not influenced by related parties or information about comparing transaction.
In case, tax payers act as the selling, rendering, or borrowing party in the above transactions, we have conducted record as follows :
- Pricing Policy and price list for the last 5 (five) years.
- Details of manufacturing cost or acquisition cost or service preparation on cost.
3 Concerning of Comparation Analysis Result Notes
Yes No
Characteristic of product (goods, service, loans, finance instrument, etc) which has been transacted
Functional Analysis which is the primary consideration of tax payer's transactions with related parties companies, all risks assumed and assets are being used
in those transactions.
The economic conditions when transactions happened.
Term of transactions, including agreement between taxpayer's with related parties from foreign countries.
Taxpayer business strategy at the time when carry out the affiliation transaction
4 Concerning of determination of Fair Price
Yes No
Methodology of price determination which applicable by Taxpayer, which shows how the fair price is acquired, and the reasons why this method is chosen,
compared to other methods.
Comparator Data used by the Taxpayer to determine of transfer price
The Application of the determination methodology of transfer price and the use of comparing data in the determination or tansfer price.
…………………………………………….
________________________________
TAXABLE YEAR
STATEMENT OF TRANSACTION WITH PARTIES OF TAX HAVEN COUNTRY RESIDENT
TIN :
TAXPAYER'S :
I IN CASE THE COMPANY HAS MADE TRANSACTION WITH PARTIES OF TAX HAVEN COUNTRY RESIDENT IN THIS TAXABLE YEAR
No Name of Transaction Colleagues Types of Transaction Country Transaction Value
1 a b c d e f g
2 a b c d e f g
3 a b c d e f g
4 a b c d e f g
5 a b c d e f g
II DETERMINATION OF TRANSACTION VALUE ABOVE, SHALL BE REFERRED TO THE TERM ARMS LENGTH ANG ORDINARY BUSINESS PRINCIPLE
YES NO
……………………………………………………
( ………………………….. )
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED

TAXABLE YEAR 2 0
LIST OF INVESTMENT FACILITIES
TIN :
TAXPAYER'S NAME :
1. IN CASE THE COMPANY HAS BEEN GRANTED TAX FACILITIES ON INVESTMENT, PLEASE EXPLAIN :
a. LETTER OF APPROVAL FROM BKPM b. MINISTER OF FINANCE DECREE
1 NUIMBER : ……………………………………………………….. 1 NUIMBER : ………………………………………………………..
2 DATE : ……………………………………………………….. 2 DATE : ………………………………………………………..
2. a. AMOUNT OF INVESTMENT APPROVED : 1. a. IN FOREX : 2a1a
b. EQUIVALENT IDR : 2a1b *)
2. IND IDR. : 2a2
3. TOTAL IDR. : 2a3
b. INVESTMENT : 1 NEW 2 EXPANSION
c. FIELD AND/OR REGION OF : ……………………………………………………………………………………………………………………………….
INVESTMENT
d. FACILITIES GRANTED : 1 INVESTMENT ALLOWANCE
2 ACCELERATED DEPRECIATION/AMORTIZATION
3 LOSS CARRIED FORWARD 4 YEAR
10% TAX ON DIVIDENDS PAID TO FOREIGN SHAREHOLDERS

5
3. INVESTMENT REALIZATION
a. THIS YEAR : Rp. a
b. UP TO THIS YEAR : Rp. b
4. TIME WHEN COMMERCIAL PRODUCTION STARTED (CPS), DATE :
5. FACILITIES OF INVESTMENT ALLOWANCE : YEAR a b IDR. **)
(5% X REALIZATION OF INVESTMENT UP TO CPS)
NOTE :
*) PLEASE USE ACTUAL CONVERTION RATE AT THE TIME OF …………………..………,
TRANSFER TO THE COMPANY'S ACCOUNT
**) COPY THE AMOUNT IN LINE 5 b TO FORM 1771-I TAXPAYER/AUTHORIZED REPRESENTATIVE
LINE 7 COLUMN (3)
( ………………………………………………….…………….. )
TAXABLE YEAR 2 0
LIST OF BRANCH MAJOR
TIN :
TAXPAYER'S NAME :
NUMBER
NO ADDRESS OF MAIN BRANCHES OFFICE TIN LOCATION OF MAIN
BRANCHES
(1) (2) (3) (4)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
dst.
NOTE :
IF NEEDED, ADDITIONAL PAGES MAY BE ADDED …………………,
(……………………………………………………….)
TAXABLE YEAR 2 0
CALCULATION OF INCOME TAX ARTICLE 26 PARAGRAPH (4)
TIN :
TAXPAYER'S NAME/PERMANENT :
IDR
1. COMMERCIAL NET INCOME : ……………………………………………………………………………
1
(BASED ON FINANCIAL STATEMENT)
2. FISCAL ADJUSTMENTS :
a. POSITIVE : IDR. 2a
b. NEGATIVE : IDR. 2b
c. TOTAL (a – b) : ………………………………………………………………………………… 2c
3. FISCAL NET INCOME : (1 + 2c) …………………………...………………………………………… 3
4. CORPORATE INCOME TAX PAYABLE : ……………………………………………………………… 4
5. TAX BASE FOR INCOME TAX ART.26 PARAGRAPH (4) : (3 - 4) ……………………………………………… 5

6. INCOME TAX ARTICLE 26 PARAGRAPH (4) 6
a PAYABLE : …… *) % X AMOUNT IN LINE 5 ………………………………………………………
b NOT PAYABLE, BECAUSE :
c PROVISIONS OF TAX TREATY INDONESIA - ……………………………………..……
d REINVESTED WHOLLY IN INDONESIA IN A NEW LIMITED COMPANY : **)

……………………………………………………………………………………………………..…
TIN : e
ADDRESS : f …………………………………………………………………………………………………………………....…
…………………………………………………………………………………………………………………....…
g CITY : ………………………………………… POSTAL CODE : h
NOTE : …………………..,
*) TAX RATE OF 20% RATE STIPULATED IN TAX TREATY
**) PLEASE ATTACH THE DOCUMENTATION OF REINVESTMENT TAXPAYER/AUTHORIZED REPRESENTATIVE
(…………………………………………………)
TAXABLE YEAR
2 0
FOREIGN TAX CREDIT
NET AMOUNT TAX DUE/PAID IN TAX CREDITABLE

NO. NAME AND ADDRESS OF FOREIGN WITHHOLDING AGENT TYPE OF INCOME (IDR) FOREIGN COUNTRY
RUPIAH VALAS (IDR)
(1) (2) (3) (4) (5) (6) (7)
1
2
3
4
5
6
7
8
9
10
dst.
JUMLAH JML
………………………,
NOTE :
* PLEASE FILL WITH THE DETAIL OF EACH WITHHOLDING RECEIPT/TAX PAYMENT TAXPAYER/AUTHORIZED REPRESENTATIVE
* COLUMN (5) IDR FILL WITH CONVERTION VALUR\E FROM THE NUMBER IN COLUMN (6) FOREX WITH USING EXCHANGE RATE
PREVAILING AT THE TIME OF TAX PAYMENT/DUE IN FOREIGN COUNTRY
* TAX CREDIT THAT CAN BE CREDITED IN COLUMN (7) SHALL BE CALCULATED USING ORDINARY CREDIT PER COUNTRY BASIS METHOD
* PLEASE COPY THE TOTAL AMOUNT OF COLUMN (7) TO FORM 1771 LETTER C LINE 8.b.
* PLEASE COPY THE TOTAL AMOUNT OF COLUMN (4) TO FORM 1771-I LINE 2.
* IF NEEDED, ADDITIONAL PAGES MAY BE ADDED. (………………………………………………….)
INDUSTRIAL CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
8A-1
COMPANIES TRANSCRIPT OF ELEMENTS CITATION
2 0
OF FINANCIAL STATEMENT
TIN :
TAXPAYER'S NAME :
I. ELEMENTS FROM BALANCE SHEET
NO. DESCRIPTION VALUE (IDR) NO. DESCRIPTION VALUE (IDR)

1. CASH AND EQUIVALENT 1. ACCOUNT PAYABLE - THIRD PARTIES
2. TEMPORARY INVESTMENTS 2. ACCOUNTS PAYABLE-RELATED PARTIES
3. ACCOUNT RECEIVABLES-THIRD PARTIES 3. INTEREST PAYABLE
4. ACCOUNT RECEIVABLES-RELATED PARTIES 4. TAXES PAYABLE
5. ACCOUNT RECEIVABLE-THIRD PARTIES 5. DIVIDENDS PAYABLE
6. OTHER RECEIVABLE - RELATED PARTIES 6. ACCRUED EXPENSES
7. ALLOWANCE FOR DOUBTFUL ACCOUNTS 7. SHORT-TERM BANK LOANS
8. INVENTORIES 8. LONG TERM DEBTS-CURRENT MATURITIES
9. PREPAID EXPENSES 9. ADVANCES

10. ADVANCES 10. OTHER CURRENT-LIABILITIES
11. OTHER CURRENT ASSETS 11. LONG-TERM DEBT-BANK LOANS
12. LONG - TERM RECEIVABLES 12. LONG-TERM DEBT-THIRD PARTIES
13. LAND AND BUILDINGS 13. LONG-TERM DEBT-RELATED PARTIES
14. OTHER FIXED ASSETS 14. DEFERRED TAX LIABILITIES

15. LESS : ACCUMULATED DEPRECIATION 15. OTHER NON-CURRENT LIABILITIES
16. INVESTMENT IN ASSOCIATES 16. CAPITAL STOCK
17. OTHER LONG -TERM INVESTMENTS 17. ADDITIONAL PAID-IN CAPITAL
18. INTANGIBLE ASSETS 18. RETAINED EARNING FROM PREVIOUS YEAR
19. DEFERRED TAX ASSETS 19. RETAINED EARNINGS
20. OTHER NON-CURRENT ASSETS 20. OTHER EQUITY
TOTAL ASSETS TOTAL LIABILITIES AND OWNER'S EQUITY
II. ELEMENTS FOM INCOME STATEMENT
NO. DESCRIPTION VALUE (IDR)

1. NET SALES
2. MATERIALS
3. DIRECT LABOUR
4. FACTORY OVERHEAD
5. MANUFACTURING COST (2 + 3 + 4)
6. WORK IN PROCESS-BEGINNING
7. WORK IN PROCESS-ENDING
8. COST OF GOOD MANUFACTURE (5 + 6 - 7)
9. FINISHED GOODS-BEGINNING
10. FINISHED GOODS-ENDING
11. COST OF GOOD SOLD (8 + 9 - 10)
12. GROSS PROFIT (1 - 11)
13. SELLING EXPENSES
14. GENERAL AND ADMINISTRATIVE EXPENSES
15. PROFIT (12 - 13 - 14)
16. OTHERS INCOME (EXPENSES)
17. NET EARNINGS OF ASSOCIATES
18. INCOME BEFORE INCOME TAX BENEFIT/(EXPENSE) (15 + 16 + 17)
19. INCOME TAX BENEFIT/(EXPENSE)
20. NET EARNINGS FROM NORMAL ACTIVITIES (18 - 19)
21. EXTRAORDINARY ITEMS
22. INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (20 + 21)
23. MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES
24. NET PROFIT (22 - 23)
III. TRANSACTION ELEMENTS WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7
NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (IDR)
DECLARATION
Understanding All The Sanctions Provided by The Law and Regulations, I Hereby Declare that The Information Stated in this Return, Including All Attachments
Provided, are True, Complete, Clear, and Under No Circumstances Whatsoever.
a.
……………………………………., (date) (month) (year)
(Place)
b. TAXPAYER AUTHORIZED/REPRESENTATIVE
c. FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)
TRADING CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
8A-2
COMPANIES TRANSCRIPT OF ELEMENTS CITATION
2 0
TIN :
TAXPAYER'S NAME :

2. TEMPORARY INVESTMENTS 2. ACCOUNTS PAYABLE-RELATED PARTIES
3. ACCOUNT RECEIVABLES-THIRD PARTIES 3. INTEREST PAYABLE
4. ACCOUNT RECEIVABLES-RELATED PARTIES 4. TAXES PAYABLE
5. ACCOUNT RECEIVABLE-THIRD PARTIES 5. DIVIDENDS PAYABLE
6. OTHER RECEIVABLE - RELATED PARTIES 6. ACCRUED EXPENSES
7. ALLOWANCE FOR DOUBTFUL ACCOUNTS 7. SHORT-TERM BANK LOANS
8. INVENTORIES 8. LONG TERM DEBTS-CURRENT MATURITIES

10. ADVANCES 10. OTHER CURRENT-LIABILITIES
11. OTHER CURRENT ASSETS 11. LONG-TERM DEBT-BANK LOANS
12. LONG - TERM RECEIVABLES 12. LONG-TERM DEBT-THIRD PARTIES
13. LAND AND BUILDINGS 13. LONG-TERM DEBT-RELATED PARTIES

15. LESS : ACCUMULATED DEPRECIATION 15. OTHER LONG - TERM LIABILITIES
16. INVESTMENT IN ASSOCIATES 16. CAPITAL STOCK
17. OTHER LONG -TERM INVESTMENTS 17. ADDITIONAL PAID-IN CAPITAL
18. INTANGIBLE ASSETS 18. RETAINED EARNING FROM PREVIOUS YEAR
19. DEFERRED TAX ASSETS 19. RETAINED EARNINGS
20. OTHER NON-CURRENT ASSETS 20. OTHER EQUITY

1. NET SALES
2. PURCHASE
3. MERCHANDISE INVENTORY - BEGINNING
4. MERCHANDISE INVENTORY - ENDING
5. COST OF GOOD SOLD (2 + 3 - 4)
7. SALES EXPENSE
8. GENERAL AND ADMINISTRATIVE EXPENSES
9. PROFIT (6 - 7 - 8)
10. INCOME/(EXPENSE) OTHER
12. INCOME BEFORE INCOME TAX (9 + 10 +11)
13. INCOME TAX BENEFIT (EXPENSE)
16. GAIN/LOSS BEFORE MINORITY INTEREST (14 + 15)
18. NET PROFIT (16 - 17)
DECLARATION
a.
……………………………………., (date) (month) (year)
(Place)

CONVENTIONAL CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
8A-3
BANKS TRANSCRIPT OF ELEMENTS CITATION
2 0
TIN :
TAXPAYER'S NAME :

1. CASH 1. OBLIGATION DUE IMMEDIATELY
2. GIRO AT CENTRAL BANK 2. DEPOSITS FROM CUSTOMERS - RELATED PARTIES
3. GIRO AT OTHER BANK - NET 3. DEPOSITS FROM CUSTOMERS - THIRD PARTIES
4. PLACEMENTS ON CENTRAL BANK - NET 4. DEPOSITS FROM OTHER BANKS
MARKETABLE SECURITIES SOLD UNDER

5. PLACEMENT ON OTHER BANKS- NET 5.
REPURCHASE AGREEMENTS, NET OF ALLOWANCE
6. MARKETABLE SECURITIES - RELATED PARTIES 6. DERIVATIVE PAYABLES
7. MARKETABLE SECURITIES - THIRD PARTIES 7. ACCEPTANCE PAYABLES

MARKETABLE SECUTIRIES PURCHASED UNDER
8. 8. TAXES PAYABLE
RESALE AGREEMENT, NET OF ALLOWANCE
9. DERIVATIVE RECEIVABLES, NET OF ALLOWANCE 9. MARKETABLE SECURITIES ISSUED
10. LOANS, NET OF ALLOWANCE 10. LOAN RECEIVED
CONSUMER FINANCING RECEIVABLES, NET OF ESTIMATED LOSSES ON COMMITMENTS AND
11. 11.
ALLOWANCE CONTIGENCIES
ACCEPTANCE RECEIVABLES, NET OF
12. 12. DEFERRED TAX LIABILITY
ALLOWANCE
13. GOVERNMENT BONDS 13. ACCRUALS LIABILITIES
14. INVESTMENTS, NET OF ALLOWANCE 14. OTHER LIABILITIES
GOODWILL - NET OF ACCUMULATED
15. 15. SUBORDINATED DEBTS
AMORTIZATION
16. FIXED ASSET 16. CAPITAL STOCK
17. LESS : ACCUMULATED DEPRECIATION 17. ADDITIONAL-PAID IN CAPITAL
18. DEFERRED TAX ASSETS 18. RETAINED EARNING FROM PREVIOUS YEAR
19. PREPAID EXPENSES 19. RETAINED EARNINGS
20. OTHER ASSETS 20. OTHER EQUITY

1. INTEREST INCOME
2. INTEREST EXPENSE
3. NET INTEREST INCOME (1 - 2)
4. OTHER OPERATING INCOME
5. OTHER OPERATING EXPENSES
6. INCOME FROM OPERATIONS(4 - 5)
7. NON-OPERATING INCOME
8. NON-OPERATING EXPENSE
9. NON-OPERATING INCOME-NET (7 - 8)
11. INCOME BEFORE INCOME TAX (3 + 6 + 9 + 10)
13. GAIN (LOSS) FROM NORMAL ACTIVITIES (12 - 13)
15. INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (13-14)
17. NET PROFIT (15 - 16)
DECLARATION
a.
……………………………………., (date) (month) (year)
(Place)

SHARIA CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
8A-4
BANKS TRANSCRIPT OF ELEMENTS CITATION
2 0
TIN :
TAXPAYER'S NAME :

1. CASH AND CASH EQUIVALENT 1. OBLIGATION DUE IMMEDIATELY
2. PALCEMENTS AT CENTRAL BANK 2. DEPOSIT (WADIAH SAVING AND GIRO)
OTHER LIABILITY (SALAM LIABILITY AND ISTISHNA
3. GIRO AT OTEHRS BANK - NET 3.
LIABILITY)
4. PLACEMENT AT OTHER BANK - NET 4. LIABILITY TO OTHER BANK
5. SECURITIES 5. RECEIVED FINANCING
RECEIVABLES (MURABAHAH, SALAM ISTISHNA,
6. 6. UNDISTRIBUTED OF PROFIT ANNOUNCED
IJAROH, ETC)
7. MUDHARABAH FINANCING 7. ZAKAT PAYABLE
8. MUSYAROKAH FINANCING 8. TAX PAYABLE
9. INVENTORIES (ASSET FOR RESALES) 9. DFERRED TAX LIABILITIES
10. ASSETS ACQUIRED FOR IJARAH 10. OTHET PAYABLE
11. ISTISHNA ASSET IN COMPLETION 11. (MUDAROBAH DEPOSIT AND SAVING) NON BANK
12. INVESTMENT 12. (MUDHARABAH DEPOSIT AND SAVING) BANK
13. FIXED ASSET 13. CAPITAL STOCK

14. LESS : ACCUMULATED DEPRECIATION 14. ADDITIONAL PAID-IN CAPITAL
15. DEFERRED TAX ASSETS 15. PREVIOUS RETAINED EARNING
16. PREPAID EXPENSES 16. RETAINED EARNING FOR THIS YEAR

1. OPERATING AVENUE
2. RIGHT OF THIRD PARTIES ON THE UNRELATED INVESTMENT RETURN]
3. MAJOR OPERATIONS INCOME-NET(1 - 2)
4. OTHER OPERATING AVENUE
5. OTHER OPERATING EXPENSES
6. INCOME FROM OPERATIONS (3 + 4 - 5)
7. NON-OPERATING REVENUE
8. NON-OPERATING EXPENSES
10. INCOME BEFORE INCOME TAX (6 + 7 - 8 + 9)
14. INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (12-13)
16. NET PROFIT (14 - 15)
DECLARATION
a.
……………………………………., (date) (month) (year)
(Place)

INSURANCE CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
8A-5
COMPANY TRANSCRIPT OF ELEMENTS CITATION
2 0
TIN :
TAXPAYER'S NAME :
NO. URAIAN NILAI (RUPIAH) NO. URAIAN NILAI (RUPIAH)

1. INVESTMENTS-TIME DEPOSITS 1. OBLIGATION TO POLICYHOLDERS
2. INVESMENTS IN SHARES OF STOCK 2. OBLIGATION FOR FUTURE POLICY BENEFITS
3. INVESTMENTS-BONDS 3. ESTIMATED OWN RETENTION CLAIMS
4. INVESTMENTS-TRADING SECURITIES 4. CLAIMS PAYABLE
5. INVESTMENTS-DIRECT SHARE 5. UNEARNED PREMIUMS
6. INVESTMENTS-LAND AND BUILDING 6. TOTAL OBLIGATION TO POLICYHOLDER
7. INVESTMENTS-MORTGAGES POLICY LOAN 7. DEPOSIT PREMIUMS
8. INVESTMENTS-INSURANCE POLICY LOANS 8. COMMISION PAYABLES
9. OTHER INVESTMENTS 9. RE-INSURANCE PAYABLES
10. CASH ON HAND AND IN BANKS 10. ACCRUED EXPENSES
11. PREMIUM RECEIVABLES 11. TAXES PAYABLE
12. RE-INSURANCE RECEIVABLES 12. DEFERRED TAX LIABILITY
13. INVESTMENT RETURN RECEIVABLE 13. OTHER LIABILITIES
14. OTHER ACCOUNT RECEIVABLES 14. CAPITAL STOCK
15. PREPAID EXPENSES 15. ADDITIONAL PAID-IN CAPITAL
DIFFERENCE IN VALUE RESULTING FROM
16. DEFERRED TAX ASSET 16. RESTRUCTURING TRANSACTION WITH ENTITIES UNDER
COMMON CONTROL
17. FIXED ASSET 17. DIFFERENCE ON REVALUATION OF FIXED ASSET
NET UNREALIZED GAIN(LOSS) ON INCREASE (DECREASE)

18. LESS : ACCUMULATED DEPRECIATION 18. IN FAIR VALUE OF AVAILABLE FOR SALE SECURITIES
19. DEFERRED ACQUISITION COST-NET 19. RETAINED EARNINGS


1. GROSS PREMIUMS
2. REINSURANCE PREMIUMS
3. DECREASE(INCREASE) IN UNEARNED PREMIUMS
4. TOTAL PREMIUMS INCOME (1 + 2 + 3)
5. NET INCOME FROM INVESTMENTS
6. OTHERS
7. TOTAL INCOME (4 + 5 + 6)
8. CLAIMS AND BENEFITS
9. RE-INSURANCE CLAIMS
10. INCREASE IN FUTURE POLICYHOLDER BENEFIT LIABILITIES AND ESTIMATED CLAIMS LIABILITIES
11. ACQUISITION COST
12. OPERATING EXPENSES
13. SELLING EXPENSES
14. GENERAL AND ADMINISTRATIVE EXPENSE
15. OTHER EXPENSES
16. TOTAL EXPENSES (TOTAL 8 TO 15)
17. INCOME FROM OPERATIONS (7-16)
19. INCOME BEFORE INCOME TAX BENEFIT/(EXPENSE) (17 + 18)
20. INCOME TAX BENEFIT/(EXPENSE)
21. GAINS (LOSSES) FROM NORMAL ACTIVITIES (19 - 20)
23. INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (21+22)
25. NET PROFIT (23-24)
DECLARATION
a.
……………………………………., (date) (month) (year)
(Place)

NON- CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
8A-6
QUALIFICATION TRANSCRIPT OF ELEMENTS CITATION
2 0
TIN :
TAXPAYER'S NAME :

2. TEMPORARY INVESTMENT 2. ACCOUNT PAYABLE-RELATED PARTIES
3. ACCOUNT RECEIVABLE-THIRD PARTIES 3. INTEREST PAYABLE
4. ACCOUNT RECEIVABLE-RELATED PARTIES 4. INTEREST TAXES
5. ACCOUNT RECEIVABLE-THIRD PARTIES 5. DIVIDEND PAYABLE
6. OTHER RECEIVABLE WITH RELATED PARTIES 6. ACCRUED EXPENSES
7. ALLOWANCE FOR DOUBTFUL ACCOUNTS 7. BANK PAYABLES
8. INVENTORIES 8. LONG-TERM DEBITS-CURRENT MATURITIES

10. PURCHASING DOWN PAYMENT 10. OTHER CURRENT-LIABILITIES
11. OTHER CURRENT ASSET 11. LONG-TERM DEBT-BANK LOANS
12. LONG - TERM RECEIVABLE 12. LONG-TERM DEBT-THIRD PARTIES
13. LAND AND BUILDING 13. LONG-TERM DEBT-RELATED PARTIES

15. ACCUMULATED DEPRECIATION 15. OTHER NON-CURRENT LIABILITIES
16. INVESTMENT IN ASSOCIATION COMPANY 16. CAPITAL STOCK
17. OTHER LONG -TERM INVESTMENT 17. ADDITIONAL PAID-IN CAPITAL
18. INTANGIBLE ASSET 18. RETAINED EARNING FROM PREVIOUS YEAR
19. DEFERRED TAX ASSETS 19. RETAINED EARNING

20. OTHER NON-CURRENT ASSET 20. OTHER EQUITY

1. NET SALES
2. BEGINNING INVENTORY
3. PURCHASE
4. ENDING INVENTORY
5. COST OF GOOD SOLD (2 + 3 -4)
7. SALES EXPENSE
8. GENERAL AND ADMINISTRATIVE EXPENSE
9. PROFIT (6 - 7 - 8)
10. INCOME/(EXPENSE) OTHER
11. NET EARNINGS FROM ASSOCIATES
12. INCOME BEFORE INCOME TAX (9 + 10 + 11)
14. GAIN (LOSS) FROM NORMAL ACTIVITIES (12 - 13)
16. GAIN/LOSS BEFORE MINORITY INTEREST (14 + 15)
18. NET PROFIT (16 - 17)
DECLARATION
a. 2 0
……………………………………., (date) (month) (year)
(Place)

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CORPORATE ANNUAL TAXABLE YEAR

1771 INCOME TAX RETURN 2 0

ATTENTION h FOLLOW INSTRUCTION IN THE MANUAL

BUSINESS CLASIFICATION : KLU :

FINANCIAL STATEMENT : AUDITED AUDIT OPINION UNAUDITED

NAME OF PUBLIC ACCOUNTANT FIRM :

1. FISCAL NET INCOME

2. FISCAL LOSS CARRIED FORWARD

3. TAXABLE INCOME (1 - 2) ……………………………………………………… 3

a. Tax Rate Article 17 paragraph (1) letter b X line 3) …………

b. Tax Rate Article 17 paragraph (2b) X line 3…………………. 4

c. Tax Rate Article 31E paragraph (1)

6. TOTAL TAX DUE (4 + 5) ………………………………………………………… 6

7. INCOME TAX BORNE BY THE GOVERNMENT (Foreign Aid Project) 7

8. a. DOMESTIC TAX CREDIT

c. TOTAL (8a + 8b) ……………………………………………………………….8c

9. a. TAX DUE AFTER CREDIT

10. PREPAID TAX :

b. NOTICE OF TAX COLLECTION (Principal only) 10b

c. TAX ARTICLE POINT 8 / DEPARTURE TAX ………………………………10c

d. TOTAL (10a + 10b + 10c) ……………………………….. 10d

11. a. UNDERPAID TAX (INCOME TAX ARTICLE 29)

12. UNDERPAID TAX ON NUMBER 11.a SETTLED ON…………………………………………………

TGL BLN THN

a. REFUNDED b. COMPENSATED WITH OUTSTANDING TAX PAYABLE

14. a. INCOME BASE FOR CALCULATION OF MONTHLY TAX

e. WITHOLDING TAX PAID BASED ON NUMBER 14a

15. a. FINAL TAX :

a. THIRD COPY OF TAX PAYMENT RECEIPT OF INCOME TAX ARTICLE 29

j. FOREIGN TAX CREDITS (Special Attachment 7A Income Tax Return Manual)*

k. POWER OF ATTORNEY (if needed)

a. TAX PAYER b. AUTHORIZED c. d.

SIGNATURE AND COMPANY SEAL

FULL NAME MANAGEMENT/ : e.

CORPORATE ANNUAL INCOME TAX RETURN

2. FOREIGN COMMERCIAL NET INCOME 2

3. TOTAL OF COMMERCIAL NET INCOME (1h + 2) ……………………………………… . 3

4. INCOME SUBJECT TO FINAL TAX

5. POSITIVE FISCAL ADJUSTMENT :

d. EXCESSIVE COMPENSATION PAID TO SHAREHOLDERS OR OTHER

6. NEGATIVE FISCAL ADJUSTMENT :

7. FACILITIES OF INVESTMENT ALLOWANCES

CORPORATE ANNUAL INCOME TAX RETURN

TIN : TAXPAYER'S NAME :

ACCOUNTING PERIOD : s.d.

(1) (2) (3) (4) (5) (6) = (3) + (4) + (5)

SALARIES, WAGES, BONUSES,

DEPRECIATION AND AMORTIZATION

7. EXPENSE RELATED TO SERVICE

8. BAD DEBT EXPENSE

10. MARKETING AND PROMOTION EXPENSE

11. OTHER EXPENSES

12. BEGINNING INVENTORY

13. ENDING INVENTORY (-/-)

14. TOTAL OF LINE 1 TO 12 MINUS LINE 13

CORPORATE ANNUAL INCOME TAX RETURN

TIN : TAXPAYER'S NAME :

WITHHOLDING OBJECT WITHHOLDING RECEIPT/TAX PAYMENT SLIP (SSP)/SSPCP

IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED

CORPORATE ANNUAL INCOME TAX RETURN

PART A : FINAL INCOME TAX

(1) (2) (3) (4) (5)

3. INCOME FROM SALES VALUES OF SHARE