In presence of minor children, it is required an authorization by the magistrate to guardian of minors specifically indicating the name of the Insurance

Company

HELVETIA VITA ASSICURAZIONI And theoutstanding capital€ 12.500,00

IN CASE OFPROXY PAYMENT TO A SOLE HEIR, PLEASE COMPLETE / FILL IN THE FOLLOWING:

The Undersigned: DEWI NOVIA ANGGREINI Signatures :

( indicate all legal heIrs of
the point B except the beneficiary ) PUTRI APRILIA

AZRIEL DARMAWAN

authorizes the Insurance Company HELVETIA VITA ASSICURAZIONI

To pay € 12.500,00 to SUBAEDA HASAN

JL. MANGGARUPI PERUMAHAN SABRINA REGENCY BLOK B 25 KEC.

Born in UJUNG PANDANG on JULY 08, 1968 and resident in
SAMBA OPU KAB. GOWA, SULAWESI SELATAN - INDONESIA

BANK DETAILS: BENEFICIARY: SUBAEDA BANK: BANK CENTRAL ASIA

ACCOUNT NUMBER: 0255444421 SWIFT: CENAIDJA

BRANCH : MAKASSAR B.I.C. CENAIDJA

SIGNATURE AUTHENTICATION

PLACE AND DATE: STAMP AND SIGNATURE OFFICIAL AUTHORITY

 LEGAL HEIR DECLARATION
SUBAEDA HASAN born in
UJUNG PANDANG On
1968
The undersigned
aware of the criminal liability provided for by law in case of misrepresentation and use of false documents
STATE :

A) in date is deceased in Mr
JAN 28, 2020 BRAZIL HAMRAN HAMZAH
born in resident in
JAKARTA JL. MANGGARUPI PERUMAHAN SABRINA REGENCY BLOK B 25 KEC. SAMBA OPU KAB. GOWA, SULAWESI SELATAN - INDONESIA

without leaving a testament or other acts of his last wishes

B) the onlv legal heirs are:

N° NAME SURNAME BORN IN ON RESIDENT IN PASSPORT VALID RELATIONSHIP

N° UNTIL WITHDECEASED
1 SUBAEDA HASAN SUBAEDA UJUNG PANDANG 08-07-1968 UJUNG PANDANG WIFE
2DEWI NOVIA ANGGREINI DEWI JAKARTA 21-11-1987 JAKARTA DAUGHTER
3PUTRI APRILIA PUTRI JAKARTA 24-04-1995 JAKARTA DAUGHTER
4 AZRIEL DARMAWAN AZRIEL JAKARTA 01-12-2004 JAKARTA DAUGHTER

C) there is no other legal heirs other than srated here

PLACE AND DATE: SIGNATURE

SIGNATURE AUTHENTICATION

PLACE AND DATE: STAMP AND SIGNATURE OFFICIAL AUTHORITY

PLEASE NOTE