Corporate Annual Income Tax Return

CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
1771/$ FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH 2 0

FORM
LANGUAGE AND US DOLLAR CURRENCY

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

TELEPHONE NUMBER : - FACSIMILE NO. -
ACCOUNTING PERIOD : to
FOREIGN DOMICILE OF HEAD OFFICE (Permanent Establisment only) :
APPROVAL TO MAIINTAIN BOOKKEEPING IN US DOLLAR CURRENCY :
NUMBER : DATE : STARTING TAXABLE YEAR :

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 US Dollar and Rupiahs must be without decimal value (see example in the manual book page.3) US $ (IDR)
(1) (2) (3) (4)
A. TAXABLE INCOME
1. FISCAL NET INCOME

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

2 2
(Copy from Special Attachment 2B Total of Column 8) ..
3. TAXABLE INCOME (1 - 2) 3 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 4
c. Tax Rate Article 31E paragraph (1)

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

8a 8a
(Copy from Form 1771-III/$ Total of Column 5)
b. FOREIGN TAX CREDIT
8b 8b
(Copy from Special Attachment 7B Total of column 7) .
C. TAX CREDITS
c. TOTAL (8a + 8b) . 8c 8c
9. a. TAX DUE AFTER CREDIT

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

10a 10a
a. MONTHLY INSTALLMENT TAX ARTICLE 25
b. NOTICE OF TAX COLLECTION (Principal only) 10b 10b
c. TOTAL (10a + 10b) ......... 10c 10c

D. INCOME TAX OVER/UNDER PAID
11. a. UNDERPAID TAX (INCOME TAX ARTICLE 29)

(9 - 10c) 11 11
b. OVERPAID TAX (INCOME TAX ARTICLE 28A)
12. UNDERPAID TAX ON NUMBER 11.a SETTLED ON.

DATE MONTH YEAR
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)
Notes : Rupiah's column should be filled with the conversion number from item in column US$, using tax rate which is valid in the end of taxable year
F.1.1.32.15
Form 1771/$ Page 2
US $ (IDR)
(1) (2) (3)
14. a. INCOME BASE FOR CALCULATION OF MONTHLY TAX

E. MONTHLY INSTALLMENT OF ART.25 FOR CURRENT
14a 14a
INSTALLMENT ..
b. FISCALL LOSS CARRIED FORWARD :
14b 14b
(From Special Attachment 2B Total of Column 9)
14c 14c
c. TAXABLE INCOME (14a - 14b) ..
d. TAX DUE
14d 14d
YEAR
(Tax Rate from Part B line 4 X 14c)
e. 14e
WITHOLDING TAX PAID BASED ON NUMBER 14a 14e
14f 14f
f. INCOME TAX MUST BE PAID (14d - 14e) .......
14g 14g
g. INCOME TAX ARTICLE 25 : (1/12 x 14f) .
Notes : Rupiah's column should be filled with the conversion number from item in column US$, using tax rate which is valid in the end of taxable year
F.FINAL TAX AND NON-
15. a. FINAL TAX :

TAXABLE INCOME
15a 15a
(From Form 1771-IV/$ Total Part A Column 5)
b. NON-TAXABLE INCOME :
GROSS INCOME
15b 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 3B, 3B-1. and 3B-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 CITATION OF FINANCIAL STATEMENT (Special Attachment 8B-1 /8B-2 /8B-3 /8B-4 /8B-5 /8B-6)*
d. DEPRECIATION AND AMORTIZATION TABLES (Special Attachment 1B of the Annual Income Tax Return Manual)*
e. CALCULATION OF FISCAL LOSS CARRIED FORWARD (Special Attachment 2B of Income Tax Return Manual)*
H. ATTACHMENTS
f. INVESTMENT FACILITIES PROVIDED (Special Attachment 4B of the Income Tax Return Manual)
g. LIST OF MAJOR BRANCHES (Special Attachment 5B 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 6B of Income Tax Return Manual)*
j. FOREIGN TAX CREDITS (Special Attachment 7B Income Tax Return Manual)*
k. POWER OF ATTORNEY (if needed)
l. ..
m.
n.
* All Attachment above can be downloaded on website http://www.pajak.go.id. or take it at the nearest Tax Office.
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. TAX PAYER b. AUTHORIZED c. d.

REPRESENTATIVE (place) date month year
SIGNATURE AND COMPANY SEAL :
FULL NAME OF
MANAGEMENT/ : e.
REPRESENTATI VE
TIN : f.
F.1.1.32.15
ATTACHMENT - I
###
###
TAXABLE YEAR
CORPORATE ANNUAL INCOME TAX RETURN
1771 - I/$
FORM
FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH

MINISTRY OF FINANCE LANGUAGE AND US DOLLAR CURRENCY
2 0
DIRECTORATE GENERAL OF TAXES
CALCULATION OF FISCAL NET INCOME
TIN :
IDENTITY
TAXPAYER'S NAME :
NO DESCRIPTIONS US $
(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 7B 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
ASSOCIATED PARTIES AS A CONSIDERATION OF WORK PERFOMED
5d
.. .
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 to 5l .
6. NEGATIVE FISCAL ADJUSTMENT :
6a
a. LESS COMMERCIAL DEPRECIATION UNDER FISCAL DEPREC .
6b
b. LESS COMMERCIAL AMORTIZATION UNDER FISCAL AMORTIZATION .
6c
c. DEFERRED INCOME .
6d
d. OTHER NEGATIVE FISCAL ADJUSTMENTS .
6e
e. TOTAL 6a to 6d .
7. FACILITIES OF INVESTMENT ALLOWANCES

7b
YEAR 7a (From Special Attachment 4B 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.1.1.32.37
ATTACHMENT - II
1771 - II/$
TAXABLE YEAR
FORM

MINISTRY OF FINANCE FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE AND US DOLLAR CURRENCY
2 0
DETAILS OF COST OF GOOD SOLD, OTHER OPERATING EXPENSE AND COMMERCIAL NON-OPERATING EXPENSE
IDENTITY
TIN : TAXPAYER'S NAME :
COST OF GOOD SOLD OTHER OPERATING EXPENSE NON-OPERATINNG EXPENSE TOTAL

NO DETAILS
(US $) (US $) (US $) (US $)
(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.1.1.32.55
ATTACHMENT- III
1771 - III/$
TAXABLE YEAR
FORM

MINISTRY OF FINANCE FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE AND US DOLLAR CURRENCY
2 0
FOREIGN TAX CREDIT
TAXPAYER'S NAME:
IDENTITY
TIN :
WITHHOLDING OBJECT INCOME TAX WITHHELD WITHHOLDING RECEIPT/TAX PAYMENT SLIP (SSP/SSPCP)
NAME AND TIN
NO
WITHHOLDING AGENT TYPES OF INCOME/ (US $) (US $) (IDR) NUMBER DATE
(1) (2) (3) (4) (5) (6) (7) (8)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
etc
TOTAL TTL
Notes :
h Filled with calculation of each Withholding Tax Receipt. Page - from page Attachment-III
h Copy of Total Income Tax Article 22, Income Tax Article 23 and Income Tax Article 26 column (5) to Form 1771/$ Letter C Line 8.a.
IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED

D.1.1.32.32
ATTACHMENT - IV
###
###
TAXABLE YEAR
1771 - IV/$
FORM

MINISTRY OF FINANCE LANGUAGE AND US DOLLAR CURRENCY
2 0
FINAL INCOME TAX AND NON-TAXABLE INCOME
TIN :
IDENTITY
TAXPAYER'S NAME :
PART A : FINAL INCOME TAX

INCOME TAX PAYABLE
TAX BASE RATE (IDR)
NO TYPES OF INCOME
(IDR) (%) (US$) (IDR)
(1) (2) (3) (4) (5) (6)
1. INTEREST INCOME ON TIME
DEPOSITS/OTHER SAVINGS AND DISCOUNT
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
5. INCOME FROM
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
CONSTRUCTION RELATED FEE :
a. CONTRUCTOR
8.
b. DESIGNER
c. CONSTRUCTION SUPERVISOR
9. GROSS SALES OF REPRESENTATIVE OFFICE
10. GROSS INCOME OF FOREIGN

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

CAPITAL MARKET
14.
etc ..
TOTAL PART A TPA
Copy of Form 1771/$ letter F line 15 point a
Note : Column (5) US$ should be filled with convertion number of item in column (6) Rupiah, using rate which is valid on the date of withholdinng tax
PART B : NON-TAXABLE INCOME
GROSS INCOME
NO TYPES OF INCOME
(US$)
(1) (2) (3)
1. DIVIDEND FROM INVESTMENT/OWNERSHIP OF SHARES OF THE INDONESI

BUSINESS ENTITIES (Article 4 Paragraph (3) Item f of Income Tax Law)
2. 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
3.
etc ..
TOTAL PART B TPB
Copy to Form 1771/$ letter F line 15 point b

IF NEEDED, ADDITIONAL PAGES MAY BE ADDEED Page - from page Attachment-IV
D.1.1.32.40
FORM
ATTACHMENT - V
TAXABLE YEAR
1771 - V/$ FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE AND US DOLLAR
CURRENCY 2 0
MINISTRY OF FINANCE h LIST OF SHAREHOLDERS/CAPITAL OWNERS AND TOTAL DIVIDENDS DISTRIBUTED
DIRECTORATE GENERAL OF TAXES h 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 DIVIDEND
NO NAME AND ADDRESS TIN
(US$) % (US$)
(1) (2) (3) (4) (5) (6)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
etc
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.
etc
IF NEEDED, ADDITIONAL PAGES MAY BE ADDEED Page - from page Attachment-V
D.1.1.32.41
ATTACHMENT - VI
TAXABLE YEAR
FORM
1771 - VI/$ FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE

AND US DOLLAR CURRENCY
MINISTRY OF FINANCE h LIST OF CAPITAL CONTRIBUTION IN AFFILIATION COMPANY 2 0
DIRECTORATE GENERAL OF TAXES h LIST OF PAYABLE FROM SHAREHOLDERS AND/OR AFFILIATION COMPANY
h LIST OF ACCOUNT RECEIVABLE TO SHAREHOLDERS AND/OR AFFILIATION COMPANY
TIN :
IDENTITY
TAXPAYER'S NAME :
PART A : LIST OF CAPITAL CONTRIBUTION IN AFFILIATION COMPANY

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

TOTAL LOAN INTEREST/
NO NAME TIN YEAR
(US$) 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 COMPANY

TOTAL LOAN INTEREST/
NO NAME TIN YEAR
(US$) 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 - from page Attachment-VI
D.1.1.32.42
SPECIAL ATTACHMENT 1B
FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE
AND US DOLLAR CURRENCY
FOR TAXABLE YEAR 2 0

LIST OF FISCAL DEPRECIATION AND AMORTIZATION
MONTH/ BEGINNING BALANCE DEPRECIATION/AMORTIZATION FISCAL DEPRECIATION/AMORTIZATION

COST OF ACQUISITION
GROUP / TYPES OF ASSETS YEAR OF METHOD IN CURRENT YEAR NOTE
ACQUISITION (US$) (US$) 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 FISCAL LOSS CARRIED FORWARD
NO YEAR. YEAR. YEAR. YEAR. YEAR. YEAR.

YEAR IDR
(THIS TAXABLE YEAR) (CURRENT 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 THIS 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
(..)
FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING
IN ENGLISH LANGUAGE AND US DOLLAR CURRENCY
FOR TAXABLE YEAR

STATEMENT OF TRANSACTION WITH RELATED PARTIES
TIN :
TAXPAYER'S NAME :
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
Determination of Price Method

No Name Types of Transaction Transaction's Value Reasons of the use of Method
shall be used
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 3B-1
FOR TAXABLE YEAR
STATEMENT OF TRANSACTION IN RELATED PARTIES
TIN :
TAXPAYER'S NAME/PERMANENT ESTABLISHMENT :
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 Taxpayer'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.
________________________________
FOR CORPORATION PERMITTED TO MAINTAIN
BOOKKEEPING IN ENGLISH LANGUAGE AND US DOLLAR
CURRENCY
FOR TAXABLE YEAR
STATEMENT OF TRANSACTION WITH PARTIES OF TAX HAVEN COUNTRY RESIDENT
TIN :
TAXPAYER'S NAME :
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, STIPULATED BY USING TERM ARMS LENGTH AND ORDINARY BUSINESS PRINCIPLE
YES NO

( .. )
IF NEEDED, ADDITIONAL PAGES MAY BE ADDEED


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. IN FOREX : 2a1
2. EQUIVALENT US$ : 2a2 *)
3. IN US$ : 2a3
4. TOTAL US$ : 2a4
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

5
SHAREHOLDERS
3. INVESTMENT REALIZATION
a. THIS YEAR : US$ a
b. UP TO THIS YEAR : US$ b
4. TIME WHEN COMMERCIAL PRODUCTION STARTED (CPS), DATE :
5. FACILITIES OF INVESTMENT ALLOWANCE : YEAR a b US$ **)
(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)
( ... )

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
etc.
NOTE :
IF NEEDED, ADDITIONAL PAGES MAY BE ADDED ,
(.)
FOR TAXABLE YEAR 20
CALCULATION OF INCOME TAX ARTICLE 26 PARAGRAPH (4)
TIN :
TAXPAYER'S NAME/PERMANENT
:
ESTABLISHMENT
US$
1. COMMERCIAL NET INCOME :
(BASED ON FINANCIAL STATEMENT)
2. FISCAL ADJUSTMENTS :
a. POSITIVE : US$
b. NEGATIVE : US$
c. TOTAL (a b) : ..
3. FISCAL NET INCOME : (1 +/- 2c) ...
4. CORPORATE INCOME TAX PAYABLE :
5. TAX BASE FOR INCOME TAX ART.26 PARAGRAPH (4) : (3 - 4) ...

6. INCOME TAX ARTICLE 26 PARAGRAPH (4) :
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 FOREIGN COUNTRY

NO. NAME AND ADDRESS OF FOREIGN WITHHOLDING AGENT TYPE OF INCOME (US$) TAX CREDITABLE
US$ FOREX (US$)
(1) (2) (3) (4) (5) (6) (7)
1
2
3
4
5
6
7
8
9
10
etc.
TOTAL TTL
,
NOTE :
PLEASE FILL WITH THE DETAIL OF EACH WITHHOLDING RECEIPT/TAX PAYMENT TAXPAYER/AUTHORIZED REPRESENTATIVE
COLUMN (5) IDR FILL WITH CONVERTION VALUE FROM THE NUMBER IN COLUMN (6) FOREX WITH USING EXCHANGE RATE
PREVAILING AT THE TIME OF TAX PAYMENT/DUE IN FOREIGN COUNTRY
TAX CREDIT THAT CAN BE CREDITED IN COLUMN (7) SHALL BE CALCULATED USING ORDINARY CREDIT PER COUNTRY BASIS METHOD
PLEASE COPY THE TOTAL AMOUNT OF COLUMN (7) TO FORM 1771/$ 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 COMPANIES SPECIAL ATTACHMENT 8B-1
8B-1
TRANSCRIPT OF ELEMENTS CITATION OF

2 0
FINANCIAL STATEMENT
FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE AND
UNITED STATE DOLLAR CURRENCY
TIN :
TAXPAYER'S NAME :
I. ELEMENTS FROM BALANCE SHEET
NO. DESCRIPTION VALUE (US$) NO. DESCRIPTION VALUE (US$)

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. OTHER 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 EARNINGS FROM PREVIOUS YEARS
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 STATEMEN
NO. DESCRIPTION VALUE (US$)

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 WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES (PSAK) NUMBER 7
NO. PARTIES TYPES OF TRANSACTION TRANSACTION VALUE (US$)
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. ., 2 0
(Place) (date) (month) (year)
b. TAXPAYER AUTHORIZED/REPRESENTATIVE
c. FULL NAME OF MANAGEMENT/REPRESENTATIVE

(d. Signature and Company Seal)
TRADING COMPANIES SPECIAL ATTACHMENT 8B-2
8B-2

2 0
FINANCIAL STATEMENT
TIN :
TAXPAYER'S NAME :
I. ELEMENT FROM BALANCE SHEET

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. OTHER RECEIVABLE-THIRD PARTIES 5. DIVIDEND 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 ASSET 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 EARNINGS FROM PREVIOUS YEAR
19. DEFERRED TAX ASSETS 19. RETAINED EARNINGS
20. OTHER NON-CURRENT ASSETS 20. OTHER EQUITY
II. ELEMENTS FROM INCOME STATEMENT

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. ., 2 0

8B-3 CONVENTIONAL BANKS

2 0
FINANCIAL STATEMENT
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. PLACEMENTS 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
12. ACCEPTANCE RECEIVABLES, NET OF ALLOWANCE 12. DEFERRED TAX LIABILITES
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 EARNINGS 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 (3+ 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)
15. INCOME BEFORE MINORITY INTEREST IN NET EARNINGS OF SUBSIDIARIES (13-14)
17. NET PROFIT (15 - 16)
DECLARATION
a. ., 2 0

SHARIA SPECIAL ATTACHMENT 8B-4
8B-4
BANKS CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR

2 0
FINANCIAL STATEMENT
FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH LANGUAGE
AND UNITED STATE DOLLAR CURRENCY
TIN :
TAXPAYER'S NAME :

1. CASH AND EQUIVALENT 1. OBLIGATION DUE IMMEDIATELY
2. PLACEMENTS AT CENTRAL BANK 2. DEPOSIT (WADIAH SAVING AND GIRO)
OTHER LIABILITY (SALAM LIABILITY AND ISTISHNA
3. GIRO ON OTHER BANKS - NET 3.
LIABILITY)
4. PLACEMENT ON 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. DEFERRED TAX LIABILITIES
10. ASSETS ACQUIRED FOR IJARAH 10. OTHER PAYABLE
11. ASSET OF ISTISHNA 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 REVENUE
2. RIGHT OF THIRD PARTIES ON THE UNRELATED INVESTMENT RETURN
3. MAJOR OPERATIONS INCOME-NET(1 - 2)
4. OTHER OPERATING REVENUES
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. ., 2 0

INSURANCE COMPANY SPECIAL ATTACHMENT 8B-5
8A-5

2 0
FINANCIAL STATEMENT
TIN :
TAXPAYER'S NAME :
NO. DESCRIPTION VALUE (US$) NO. DESCRIPTION VALUE (IDR)

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 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. DEFFERRED TAX LIABILITIES
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. ., 2 0

NON- SPECIAL ATTACHMENT 8B-6
8B-6
QUALIFICATION CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR
TRANSCRIPT OF ELEMENTS CITATION

2 0
OF FINANCIAL STATEMENT
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 COMPANIES 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
TOTAL ASSETS TOTAL LIABILITIY AND OWNER'S EQUITY
II. ELEMENTS FROM INCOME STATEMEN

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


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CORPORATE ANNUAL INCOME TAX RETURN TAXABLE YEAR

1771/$ FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH 2 0

LANGUAGE AND US DOLLAR CURRENCY

BUSINESS CLASIFICATION : KLU :

APPROVAL TO MAIINTAIN BOOKKEEPING IN US DOLLAR CURRENCY :

NUMBER : DATE : STARTING TAXABLE YEAR :

NAME OF PUBLIC ACCOUNTANT FIRM :

1. FISCAL NET INCOME

2. FISCAL LOSS CARRIED FORWARD

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

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

c. Tax Rate Article 31E paragraph (1)

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

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

8. a. DOMESTIC TAX CREDIT

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

9. a. TAX DUE AFTER CREDIT

10. PREPAID TAX :

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

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

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

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

13. OVERPAID AMOUNT STATED IN 11.b WOULD BE :

a. REFUNDED b. COMPENSATED WITH OUTSTANDING TAX PAYABLE

14. a. INCOME BASE FOR CALCULATION OF MONTHLY TAX

(Tax Rate from Part B line 4 X 14c)

15. a. FINAL TAX :

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

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

k. POWER OF ATTORNEY (if needed)

a. TAX PAYER b. AUTHORIZED c. d.

SIGNATURE AND COMPANY SEAL :

FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH

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 :

6. NEGATIVE FISCAL ADJUSTMENT :

7. FACILITIES OF INVESTMENT ALLOWANCES

NOTES : Copy Total of Line 8 to Form 1771 Letter A Line 1.

CORPORATE ANNUAL INCOME TAX RETURN

TIN : TAXPAYER'S NAME :

COST OF GOOD SOLD OTHER OPERATING EXPENSE NON-OPERATINNG EXPENSE TOTAL

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

(1) (2) (3) (4) (5) (6) (7) (8)

IF NEEDED. ADDITIONAL PAGES MAY BE ADDEED

FOR CORPORATION PERMITTED TO MAINTAIN BOOKKEEPING IN ENGLISH

PART A : FINAL INCOME TAX

3. INCOME FROM SALES VALUES OF SHARE

CONSTRUCTION RELATED FEE :