Form A

INTEGRITY PACT

I, the undersigned, as the authorized representative of [insert the name of Applicant/Applicant’s

consortium] (“Applicant”) in the procurement for DEVELOPMENT AND OPERATION OF LNG
INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN
INDONESIA (“Project”) by PLN EPI, hereby certify on behalf of the Applicant, that we:

1. will comply with the rules under the Guidelines for Procurement of Goods/Services of PLN
EPI and prevailing laws and regulations;

2. will not do the conspiracy/settings/cooperation among the prospective Applicant and/or

users of goods/services and/or the procurement officer in relation to the Project which may
result in unfair business competition;

3. agree to be penalized if we are proven to violate anything that we have stated in this
Integrity Pact, in accordance with applicable laws and regulations.

[place], [Date] [month] 20__

[choose which appropriate and mention Name]

[signature]

(Authorized representative full name)

[position]
 Form B

STATEMENT OF INTEREST LETTER TO PARTICIPATE IN THE

PROCUREMENT OF DEVELOPMENT AND OPERATION OF LNG INFRASTRUCTURE

SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN INDONESIA

The undersigned,

Name : [Name of authorized representative

if corporation/partnership. If not corporation so individual person Name]

Position :

Act for and on : Company/Cooperation/Partnership/Individual Person

behalf of

[choose which appropriate and mention Name]

Address :
Phone/Fax :
Email :

Truly certify, that after knowing the procurement which will be implemented by PLN EPI, our
interest to participate in the procurement for DEVELOPMENT AND OPERATION OF LNG
INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN
INDONESIA.
This statement hereby made with fully consciousness and responsibility.

[place], [date] [month] 20__

Authorized Representative of Applicant

[choose which appropriate and mention Name]

[signature]

(Authorized representative full name)

[position]
 Form B.1.1

LETTER OF APPLICATION

Date :
To : PLANNING PROCUREMENT OFFICER
PT PLN ENERGI PRIMER INDONESIA

Kantor Pusat PT PLN (Persero)

Jl. Trunojoyo Blok M 1/135, Gedung 1 Lantai 5
Jakarta Selatan

Attention : Director Gas and Fuel PT PLN Energi Primer Indonesia

Reference : PROCUREMENT OF DEVELOPMENT AND OPERATION OF LNG

INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN
INDONESIA

Subject : PRE-QUALIFICATION APPLICATION

Ladies and/or Gentleman,

1. Being duly authorized to represent and act on behalf of ………………………………

(hereinafter referred to as “the Applicant”), and having reviewed and fully understood all of
the pre-qualification information provided, the undersigned hereby apply to be prequalified
by yourselves as an Applicant for PROCUREMENT OF DEVELOPMENT AND
OPERATION OF LNG INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS
POWER PLANTS IN INDONESIA.

If after your evaluation of this Application, we are prequalified as an Applicant, then it is our
intention to participate in the bidding to fund, design, build, operate and maintenance
and the remedying of any defects of LNG Infrastructures (where specified in the RFP),
for the entire Project of the DEVELOPMENT AND OPERATION OF LNG
INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN
INDONESIA.

2. We understand and confirm that the Scope of Project shall be completed.

3. We are applying for pre-qualification as a single Applicant/consortium which will be

formed by the following members*:

(*Delete as applicable and if the Applicant is to be a consortium, then complete the

 following table)

Name of Consortium:

Member: Company Name: Country of Home Office

Member (1):
(Consortium Leader)

Member (2):

Member (3):

Member (4):

Member (5):

We understand that the formation of a consortium after pre-qualification, or any change

in a prequalified Applicants (for example, addition of new member or substantial
change in share), may be accepted only with PLN EPI’s approval.

(Applicant who are not applying as a consortium for the execution and completion of
the Projects, should mark the following items 6, 7, 8 and 9 as “not applicable”, delete
the items and initial the deletions)

4. Attached to Form C is notarized copies of original relevant official documents for each
of the members of our consortium evidencing the following:

(a) legal status of each of the members;

(b) principal place of business of each of the members;
(c) place of incorporation of each of the members for any/all members who are
corporations, or
(d) place of registration and the nationality of any members who are individually
owned non-corporate organizations (delete this sub-paragraph (d) if not
applicable and initial the deletion).

5. Included in Form C, are details of our proposed consortium agreement indicating the
participation of each party in the consortium. We also specify the financial commitment
in terms of the approximate percentage of each member’s share of the total Contract
and the responsibilities for execution of the Contract.

6. Attached in Form C, are the Powers of Attorney prepared by each of the members
nominating and providing the authority for their own authorized representative to enter
into the consortium agreement, together with notarization for same.
7. We confirm that if we are requested to submit a bid, then that bid, as well as any
resulting Contract, will be

(a) signed so as to legally bind all members, jointly and severally; and
(b) submitted with a consortium agreement providing the joint and several liability of
all members in the event that the Contract is awarded to us which will confirm the
same intent and content as the attached Form C.

8. We confirm that PLN EPI or your authorized representatives are hereby authorized to
conduct any inquiries or investigations to verify the statements, documents, and
information submitted in connection with this Application, and to seek clarification from
our bankers and clients regarding any financial and technical aspects. This Letter of
Application will also serve as authorization to any individual or authorized
representative of any institution referred to in the supporting information, to provide
such information deemed necessary and as requested by yourselves to verify
statement and information provided in this application, such as the resources,
experience, and competence of the Applicant.

9. PLN EPI or its authorized representative may contact the following persons for further
information:

Name of Contact Person (1):

Position:
Telephone:
Fax:
E- mail address:
Name of Contact Person (2)
Position:
Telephone:
Fax:
E- mail address:

10. This Application is made with the full understanding that:

(a) Bids by prequalified Applicants will be subject to verification of all information

submitted for Pre-Qualification at the time of bidding;
(b) The submission of any false or misleading information shall provide sufficient
grounds for outright disqualification of the Applicant from this Project as well as
any other future Projects of PLN EPI.
(c) PLN EPI or its authorized representative reserve the right to:
i) amend the scope and value of any contracts bid under this Project; in such
event, Applicants will only be called from pre-qualified Applicants who meet
the revised requirements; and
ii) reject or accept any application, cancel the Pre-Qualification process, and
reject all applications and that any such action is final and not subject to
 appeal of any kind;
(d) The Government of Indonesia, PLN EPI or their authorized representatives shall
not be liable for any such actions and neither shall either be under any obligation
to inform the Applicant of the grounds for them.

11. The undersigned authorized representative acts in the name of and on the account of
the Applicant and declares by virtue of the Power of Attorney, that the signatory has
been granted with the authority to represent, bind, act on behalf of the Applicant, to
provide all further information that may be required for Pre-Qualification, to submit a
bid and to execute agreement for Contract with PLN EPI should same be required.

12. The undersigned declares that the statements made and information provided in this
duly completed Application, are complete, true and correct in every detail and we may
be held liable for any false statement or intentional misrepresentation made herein.

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date:
_____________________

Company Stamp: (If available)

 Form B.1.2

GENERAL INFORMATION

Name of Applicant:

Name of member of a consortium

All Applicant (single company and each the member of a consortium) applying for Pre-Qualification
are requested to complete the information in this form. Nationality information should be provided for
all Applicants and its member of consortium if the Applicant submit in the form of consortium.

Where the Applicant proposes to use named subcontractors for critical components of the Projects,
the following information should also be supplied for the specialist subcontractor(s), together with a
brief description of their specialized input.

1. Name of Applicant:

2. Head office address:

3. Name of Representative 4. Position of Representative

5. Telephone 6. e-mail:

7. Place of incorporation / registration 8. Paid-up Capital (Equivalent in US$)

9. Location(s) of Branch Office(s)

10. Detailed Scope of Participation in the Project:

11. Quality Assurance Accreditations and/or Environmental Management Accreditations and/or

 Occupational Health and Safety Management System (OHSAS)

Notes:
This is a minimum qualification requirement

List below and attach Quality Assurance and Environmental Management accreditations relating
to the company’s activities issued by ISO or other internationally recognized accreditation)
In the case of consortiums, each of Environmental Management accreditation and Occupational
Health and Safety Management System (OHSAS) accreditation requirement could be represented
by at least one member of the consortium.
12. List the title of maximum ten (10) previous typical projects performed successfully operation
by the Applicant in the last ten (10) years

13. Directors:

Years with
Name Nationality Position Years of Experience
Company

14. Nationality of Owners *

Name Nationality
1
2
3
4

Relevant official documents shall be attached to this Form to provide evidence of the following
aspects of the Applicant’s legal status;

(a) the Applicant’s principal place of business; and

(b) the Applicant’s place of incorporation including its member of consortium (if the Applicant submit
in the form of consortium).
The following shall also be attached to this Form:

(a) Professional certificates, licenses or the like relating to the Applicant’s activities issued by
competent authorities
(b) Quality Assurance and Environmental Management accreditations relating to the Applicant’s
activities issued by ISO or other internationally recognized accreditation (In the case of
consortiums, each of Environmental Management accreditation and Occupational Health and
Safety Management System (OHSAS) accreditation requirement could be represented by at
least one member of the consortium).
 Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date:
_____________________

Company Stamp: (If available)

 Form B.1.3

GENERAL EXPERIENCE RECORD

Name of Applicant or member of a consortium

(a) To prequalify, the Applicant (or any of their members in case of consortium) must have
themselves completed the requisite minimum number of specified projects necessary to pass
the Minimum Qualification Requirements, as set out in the Pre-Qualification Document -
Instructions to Applicants.
(b) Consortium Leader, shall have majority share of the work should provide details of those works
under the project for which the Applicant was directly responsible.
(c) A separate Form shall be used for each project and complete details shall be provided in order
that compliance with all of the Minimum Qualification Requirements is clearly demonstrated.
(d) Forms shall be numbered Form No. B.1.3-a, B.1.3-b, etc.
(e) All values should be based on the currencies of the contracts converted into US dollars at the
date of substantial completion, or for current contracts at the time of award. The information is
to be summarized, in this Form for each contract completed or under execution, by the
Applicant or by each member of a consortium.
(f) Applicants are advised that the Planning Procurement Officer may wish to obtain confirmation
regarding the Applicant’s performance from respective employers on these previous projects.
(g) The Applicant shall attach to this Form, evidence of involvement and completion comprising
either certified copies of contract completion certificates, particular certificates prepared by the
employer or like official documents issued by respective employers or authorized project
consultants.
 Form B.1.3-a

PARTICULAR EXPERIENCE RECORD AS EPC CONTRACTOR OF LNG

REGASIFICATION FACILITY (LAND BASED TERMINAL AND/OR FLOATING
TERMINAL) OR LNG PLANT

Name of Applicant:

Name of member of a consortium, if partnership with other companies

Refer to Instructions to Applicants, Clause 8.1:

The Applicant must demonstrate that he has successful as EPC contractor of LNG
Regasification facility (land-based terminal and/or Floating Terminal) or LNG Plant, within the
last ten (10) years
1 Name of Contract
2 Country and Location
3 Name of Employer
4 Name and position of Employer’s
representative to contact
5 Representative’s address, telephone, facsimile
numbers and e-mail.
6 Contract Role: (check one of the following):
i. Sole contractor and operator
ii. Consortium Leader in a JV/JO or
consortium
iii. Member in a JV/JO or consortium
7 Value of Contract in specified currencies at
completion or at date of award for current
contracts:
state name of currency:
If sole contractor and operator insert total
__________________________
contract amount:
Equivalent value US$
__________________________
state name of currency:
If member in a consortium, insert
__________________________
responsible contract amount:
Equivalent value US$
__________________________
8 Date of award
9 Date of completion
10 Contract duration
(indicate in years and months)
11 Specified Requirements:
(The following is a listing of selected items of
the specified minimum qualifying requirements.
For Clarity the Applicant is to answer each
question and insert actual data where required
against each item)
Date of Completion Specified in Taking-Over
Certificate: “Yes” or “No” & __________year?
(was the project completed in last ten (10)
years between 2012 and 2022)?

Share of the Project: “Prime/Consortium Leader” or

(was a Leader of joint operation, joint venture, “member” & __________%?
or consortium)

Project EPC contractor:

(Was the project includes Engineering, (state “yes” or “no”)
Procurement, Construction for EPC Contractor)
Licenses for contractor (if applicable)

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date:
_____________________

Company Stamp: (If available)

 Form B.1.3-b

PARTICULAR EXPERIENCE RECORD AS OPERATION AND MAINTENANCE

CONTRACTOR OR OWNER OF STORAGE OR REGASIFICATION FACILITY OR LNG
PLANT (LAND BASED TERMINAL AND/OR FLOATING TERMINAL)

Name of Applicant:

Name of member of a consortium, if partnership with other companies

Refer to Instructions to Applicant, Clause 8.1:

The Applicant must demonstrate that he has successful as Operation and Maintenance of
Contractor or Owner of Storage or Regasification facility or LNG Plant (land based terminal
and/or floating terminal), within the last ten (10) years

1 Name of Contract

2 Country and Location

3 Name of Employer

4 Name and position of Employer’s

representative to contact
5 Representative’s address, telephone, facsimile
numbers and e-mail.
6 Contract Role: (check one of the following):

i. Sole Contractor/Operator
ii. Consortium Leader in a JV/ JO or
consortium or SPC
iii. Member in a JV/ JO or consortium or SPC
7 Value of Contract in specified currencies at
completion or at date of award for current
contracts:
state name of currency:
If sole contractor/operator insert total __________________________
contract amount: Equivalent value US$
__________________________
 If member in a joint venture/ joint state name of currency:
operation/ consortium, insert responsible __________________________
contract amount: Equivalent value US$
__________________________
8 Date of award

9 Date of completion

10 Contract duration
(indicate in years and months)
11 Specified Requirements:
(The following is a listing of selected items of
the specified minimum qualifying requirements.
For Clarif y the Applicant is to answer each
question and insert actual data where required
against each item)
Date of Completion Specified in Taking-Over
Certificate: “Yes” or “No” & __________year?
(was the project completed in last ten (10)
years between 2012 and 2 02 2?)

Share of the Project:

__________%?
(Applicant shall have a minimum ten percent
(10%) share of the respective project)

Licenses for Operation and Maintenance (if

applicable)

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date:
_____________________

Company Stamp: (If available)

 Form B.1.3-c

PARTICULAR EXPERIENCE RECORD AS LNG MARINE TRANSPORTER

Name of Applicant:

Name of member of a consortium, if partnership with other companies

Refer to Instructions to Applicants, Clause 8.1:

The Applicant must demonstrate that he has successful as LNG marine transporter within the
last ten (10) years

1 Name of Contract

2 Country and Location

3 Name of Employer

4 Name and position of Employer’s

representative to contact

5 Representative’s address, telephone, facsimile

numbers and e-mail.

6 Contract Role: (check one of the following):

i. Owner or operator

ii. Leader in a JV/JO or consortium or SPC

iii. Member in a JV/JO or consortium or SPC

7 Value of Contract in specified currencies at

completion or at date of award for current
contracts:

state name of currency:

If sole contractor and operator insert total __________________________
contract amount:
Equivalent value US$

__________________________
 state name of currency:
If member in a consortium, insert __________________________
responsible contract amount:
Equivalent value US$

__________________________

8 Date of award

9 Date of completion

10 Contract duration

(indicate in years and months)

11 Specified Requirements:

(The following is a listing of selected items of

the specified minimum qualifying requirements.

For Clarity the Applicant is to answer each

question and insert actual data where required
against each item)

Date of Completion:

(was the project completed in last ten (10) “Yes” or “No” & __________year?
years between 2012 and 2022)?

Share of the Project:

(was a Leader of joint operation, joint venture, “Prime/Consortium Leader” or

or consortium) “member” & __________%?

Project EPC contractor:

(state “yes” or “no”)
(Was the project includes Engineering,
Procurement, Construction for EPC Contractor)

Licenses for contractor (if applicable)

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date:
_____________________

Company Stamp: (If available)

 Form B.1.4.a

SUMMARY SHEET: CURRENT CONTRACT / PROJECT COMMITMENTS / WORKS IN PROGRESS

Name of Applicant or member of a consortium

Certified copies of each relevant document of each project shall be attached

Name and Address

Estimated Short Value of
of the client Name of Total Project Cost Role in
No. completion Project Applicants
(including phone Project (in USD) the project
date Description Contribution
number)
 Form B.1.4.b

SUMMARY SHEET: PROJECTS COMPLETED WORKS

Name of Applicant or member of a consortium

Certified copies of each relevant document of each project shall be attached

Name and Address of Name Total Project Value of

Cost Date Completed Short Project Role in
No. the client (including of Applicants
Completed on Time Description the project
phone number) Project (in USD) Contribution
 Form B.1.4.c

MANAGEMENT KEY PERSONNEL

Name of Applicant or member of a consortium

No Name of Personnel Position

Certified copies of each relevant document shall be attached

Applicant shall provide evidence of organizational structure and management key personnel relevant
to the scope of experiences demonstrated by the curriculum vitae.
 Form B.1.4.d

COMPETENT KEY PERSONNEL

Name of Applicant or member of a consortium

No. Name of Personnel Position Expertise(s) Certification(s)

Certified copies of each relevant document shall be attached

Applicant shall provide evidence of experience and availability of competent key personnel relevant
to the scope of experiences demonstrated by the curriculum vitae or certificate of competency.
 Form B.1.5

SUMMARY SHEET: LIST OF TECHNICAL EXPERTISE

Name of Applicant or member of a consortium

Technical Expertise
Name and Address of the Name and Total Project Contributed
Role of Value of Applicant
No. client (including phone Description Cost LNG Land Based Terminal
Applicants Contribution
number) of Project (in USD) and/or Floating Terminal, or
LNG Plant.
 Form B.1.6

SUMMARY SHEET: LIST OF APPLICANT’S FACILITIES

Name of Applicant or member of a consortium

Certified copies of certificate final acceptance of each project shall be attached

Applicant’s facilities
Name and Total Project
Name and Address of the client Role of Value of Applicant
No. Description Cost LNG Land
(including phone number) Applicants Floating Facilities
of Project (in USD) Based
Terminal
Terminal
 Form C

COOPERATION STATEMENT

Date :
To : PLANNING PROCUREMENT OFFICER
PT PLN ENERGI PRIMER INDONESIA

Kantor Pusat PT PLN (Persero)

Jl. Trunojoyo Blok M 1/135, Gedung 1 Lantai 5
Jakarta Selatan

Attention : Director Gas and Fuel PT PLN Energi Primer Indonesia

Reference : PROCUREMENT OF DEVELOPMENT AND OPERATION OF LNG

INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER
PLANTS IN INDONESIA

Subject : PRE-QUALIFIED APPLICATION

Dear Sirs,

The undersigned of this declaration of cooperation are by means of attached Powers of Attorney
legally authorized to act with regard to the Pre-Qualification, bidding (and if successful), the
execution, completion, maintenance for the PROCUREMENT OF DEVELOPMENT AND
OPERATION OF LNG INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER
PLANTS IN INDONESIA (“Project”) and on behalf of our consortium.

Capitalized terms not otherwise defined herein shall have the meanings given to them in the
Amended and Restated Pre-Qualification Document in relation to the Project.

We hereby declare:

1. That we will legalize a consortium agreement in case that a Contract for the
PROCUREMENT OF DEVELOPMENT AND OPERATION OF LNG INFRASTRUCTURE
SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN INDONESIA is awarded to
the consortium;
2. That we have nominated ___________________ [name of the Consortium Leader] as
Consortium Leader of the consortium for the purpose of this Pre-qualification and bid;
3. That we have authorized Mr./Ms. _____________ [name of the person who is authorized to
act as the Authorized Representative on behalf of the consortium] to act as the only
Applicant’s Representative in the name and on behalf of the consortium.
4. That all members of the consortium shall be liable jointly and severally for the execution of
 the Contract;
5. That this consortium is an association constituted for the purpose only for the execution of
the PROCUREMENT OF DEVELOPMENT AND OPERATION OF LNG
INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER PLANTS IN
INDONESIA;
6. That if PLN EPI accepts the bid of this consortium, it shall not be modified in its composition
or constitution until the completion of the Contract without the prior consent of PLN EPI;
7. That each member’s approximate share of the Project stated as a percentage of the
Contract amount shall be as follows:

Description of Work, Approximate Share of the Project

Member Name Scope Participation and (as a percentage of the Contract
Responsibility amount)

Consortium Leader
(1)

Member (2)

Member (3)

Member (4)

Member (5)

8. That the names and positions of the proposed consortium’s Authorized Representatives as
well as organizations’ names and addresses are as follows:

Consortium Leader (1) Organization Name:

Signature of Representative

Name of Representative

Position of Representative

Date

Address

Telephone

Facsimile

E- Mail Address
Member (2) Organization Name:

Signature of Representative

Name of Representative

Position of Representative

Date

Address

Telephone

Facsimile

E- Mail Address

Member (3) Organization Name:

Signature of Representative

Name of Representative

Position of Representative

Date

Address

Telephone

Facsimile

E- Mail Address

Member (4) Organization Name:

Signature of Representative

Name of Representative

Position of Representative

Date

Address

Telephone
Facsimile

E- Mail Address

Member (5) Organization Name:

Signature of Representative

Name of Representative

Position of Representative

Date

Address

Telephone

Facsimile

E- Mail Address

The following shall be attached to this Form:

1. Consortium Agreement or Letter of Intent

2. Power of Attorney signed by authorized officer of each member of the consortium to appoint
the authorized representative of the Applicant
 FORM D

STATEMENT LETTER OF CSMS COMPLIANCE

I, undersigned, as the authorized representative of [insert the name of Applicant/Applicant’s

consortium] (“Applicant”) in the procurement for PROCUREMENT OF DEVELOPMENT AND
OPERATION OF LNG INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER
PLANTS IN INDONESIA (“Project”) by PLN EPI, hereby stated on behalf of the Applicant, we
will comply Contractor Safety Management System (CSMS) in PT PLN (Persero)

[place], [Date][month] 20__

[choose which appropriate and mention Name]

[signature]

(Authorized representative full name)

[position]
 Form E

HISTORICAL CRITERIA FORM

Name of Applicant:

(a) Applicants (including each of the members of an Applicant’s consortium) should provide
information on any historical records pursuant to Clause 8.3 of the Pre-Qualification
Document.
(b) A separate sheet should be prepared for each member of the consortium.
(c) If there have been no disputes involving litigation or arbitration, Applicant should state
"none".

Year Client and Award/Records Cause of Disputed amount

Project against Applicant litigation/matter in (current value, US$
dispute/matter in equivalent) if any
question

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date: _____________________

Company Stamp: (If available)

 FORM F

STATEMENT LETTER OF VALIDITY OF APPLICANT INFORMATION

I, the undersigned duly authorized to represent [--] or consortium of [--] (the “Applicant”),
hereby declare that the documents provided in joining to this Pre-Qualification stage (either
proposal and form attached therein) are true and correct to the best of my knowledge and belief
and I undertake to inform you of any changes therein, immediately.

I hereby authorize for revealing the information furnished on this form on behalf of Applicant. In
any case of the information in such documents submitted to this Pre-Qualification stage is found
to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for
it.

The undersigned declares that statement made is true and correct in every detail. Any of the
falsification of submitted documents could result in disqualification and/or termination as a
prospective Applicant in this Pre-Qualification stage.

....................., ........................20

On behalf of the Applicant,

Authorized Representative

Meterai/
Stamp duty
Rp .10000
Signature

__________________________
[Name]
 Form G

STATEMENT LETTER OF NOT IN BANKRUPTCY, UNDER COURT SUPERVISION

OF COURT NOR SUSPENDED

I, undersigned, as the authorized representative of [insert the name of Applicant/Applicant’s

consortium] (“Applicant”) in the procurement for PROCUREMENT OF DEVELOPMENT AND
OPERATION OF LNG INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER
PLANTS IN INDONESIA (“Project”) by PLN EPI, hereby stated on behalf of the Applicant, are
not currently in the state of bankruptcy nor in the process of filing a bankruptcy, nor under the
scrutiny of the court, nor under court supervision, nor under order to terminate the business
activities, nor having temporarily ceased/suspended the activities, nor subject to criminal
investigations.

[place], [Date][month] 20__

[choose which appropriate and mention Name]

[signature]

(Authorized representative full name)

[position]
 Form H

STATEMENT LETTER OF NOT BLACKLISTED BY PLN GROUP OR GOI’S

AGENCY OR OTHER INTERNATIONAL INSTITUITION

I, undersigned, as the authorized representative of [insert the name of Applicant/Applicant’s

consortium] (“Applicant”) in the procurement for PROCUREMENT OF DEVELOPMENT AND
OPERATION OF LNG INFRASTRUCTURE SERVICES FOR CLUSTERS OF GAS POWER
PLANTS IN INDONESIA (“Project”) by PLN EPI, hereby stated on behalf of the Applicant, are
not currently included in any list of sanctions by any institutions related to PLN Group or any
similar Indonesian State Owned Enterprise as PLN, either as a sole company or as a member
of a consortium of JV.

We will immediately inform PLN EPI, in the event if this situation changes or occurs at a later
stage.

We acknowledge PLN EPI’s right to cancel or exclude our company from the prequalification
process or from the DPT list in the event if this situation occurs at a later stage or if our
statement is found to be false or untrue.

This statement is made truthfully and to be used accordingly.

[place], [Date][month] 20__

[choose which appropriate and mention Name]

[signature]

(Authorized representative full name)

[position]
 Form I

CATEGORY OF APPLICATION

The Applicant submits this Application to pre-qualify on the basis of its experience in the
following components (and is seeking to pre-qualify for):
Please mark either Item 1 or relevant parts of Item 2 below with  as relevant

Ite Component Please Indicate

m with  or Not
Applicable
1 All components of LNG Infrastructure
If this row is marked with  do not mark any box in item 2
below
2 The following component or components of LNG
Infrastructure
Mark one or two of the rows below with  as relevant. If
seeking to pre-qualify for all rows in this item 2, mark Item 1
instead and leave rows in this Item 2 as ‘Not Applicable’
2.1 EPC contractor of: LNG regasification facility (land-based or
floating terminal), or LNG plant
2.2 Operation and maintenance contractor or owner of: LNG
storage or regasification facility or LNG plant
2.3 The procurement and delivery of and vessel scheduling for,
ships or other vessels for marine transport of LNG

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date: _____________________

Company Stamp: (If available)

 Form J

OPTIONAL AND NON-BINDING NOMINATION OF CLUSTER OR CLUSTERS THE

APPLICANT IS SEEKING TO BE AWARDED FOR THE PROVISION OF THE LNG
INFRASTRUCTURE SERVICES

Name of Applicant:

1. PLN EPI confirms this form is optional and Applicant is not obliged to submit or complete
this Form J. If this Form J is not completed or not submitted as part of an Application,
there will be no adverse evaluation of the Applicant based on the non-completion or non-
submission.
2. The Applicant nominates to provide the LNG Infrastructure for the Cluster or Clusters
identified in the second column below.
3. The nomination in this Form J is not binding on PLN EPI or the Applicant and if the
Applicant succeeds in becoming a Qualified Applicant the completion of this form does
not require the Applicant to submit a response to any RFP or RFPs for a Cluster
nominated below (or to submit an RFP response at all).
4. Nothing in this Form J limits the discretion of PLN EPI to issue an RFP or RFPs to a
Qualified Applicant for a specific Cluster or Clusters or all Clusters.

Cluster Nominated by Applicant

(Yes or No)

Kalimantan Cluster [please completed with Yes or No]

Nusa Tenggara Cluster [please completed with Yes or No]

Papua Utara Cluster [please completed with Yes or No]

Papua Selatan Cluster [please completed with Yes or No]

Sulawesi-Maluku Cluster [please completed with Yes or No]

Applicant’s Authorized Representative:

Signature: _____________________

Name : _____________________

Position: _____________________

Date: _____________________

Company Stamp: (If available)