form 1721 a1 2013 moozhill cosl deborah 02 04 2014
TRANSCRIPT
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 1
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Moozhil Job J
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,02023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMATThis is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 2
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Cheng Meng Jian
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : MARRIED X NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / TK/ 0 HB/
OCCUPATION : Rig Superintendent PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,02023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 3
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Tetrault, Thomas Daniel
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Equipment Supervisor PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,02023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 4
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Ben, Adriano
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 2 TO 0 7
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 345,147,660
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 345,147,660
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 345,147,660 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 345,147,660
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 690,295,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 690,295,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 182,506,200
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 91,253,100
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 91,253,100
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 91,253,10023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 0 7 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 5
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Cruse, Shannon
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 2 TO 0 5
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 227,078,500
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 227,078,500
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 227,078,500 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 227,078,500
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 881,235,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 881,235,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 179,244,600
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 59,748,200
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 59,748,200
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 59,748,20023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 0 5 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 6
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Singh Saini, Kuldip
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Superintendent PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,02023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 7
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Jim Hao
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : MARRIED X NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / TK/ 0 HB/
OCCUPATION : Manager PERIOD OF INCOME GENERATION 0 1 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 1,176,351,550
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 1,176,351,550
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 1,176,351,550 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 1,176,351,550
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 1,176,351,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 1,176,351,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 357,486,360
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 357,486,360
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 357,486,360
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 357,486,36023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 8
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Strickland, Charles
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Superintendent PERIOD OF INCOME GENERATION 0 2 TO 0 3
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 113,422,650
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 113,422,650
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 113,422,650 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 113,422,650
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 680,535,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 680,535,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 178,992,600
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 29,832,100
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 29,832,100
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 29,832,10023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 2 9 0 3 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 0 9
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Donaldson David
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,03023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 0
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Konclus Rimantas
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 227,078,500
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 227,078,500
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 227,078,500 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 227,078,500
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 681,235,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 179,244,600
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 59,748,200
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 59,748,200
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 59,748,20023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 0 5 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 1
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : James Pereira
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Crew PERIOD OF INCOME GENERATION 0 2 TO 0 8
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 227,360,925
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 227,360,925
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 227,360,925 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 227,360,925
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 389,761,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 389,761,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 80,928,300
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 47,208,175
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 47,208,175
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 47,208,17523 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 0 0 8 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 2
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Yao Hai Sen
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : General Manager PERIOD OF INCOME GENERATION 0 1 TO 0 4
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 437,853,350
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 437,853,350
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 437,853,350 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 437,853,350
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 1,313,560,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 1,313,560,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 339,068,000
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 113,022,667
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 113,022,667
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 113,022,66723 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 0 0 4 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 3
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Rupesh, Berry
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Superintendent PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,02023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 4
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Strachan, Ian
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : General Manager PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 1,309,557,425
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 1,309,557,425
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 1,309,557,425 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 1,309,557,425
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 1,428,608,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 1,428,608,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 448,298,880
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 410,940,640
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 410,940,640
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 410,940,64023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 5
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Yin Song
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 6 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 450,058,510
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 450,058,510
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 450,058,510 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 450,058,510
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 771,528,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 771,528,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 211,750,080
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 123,520,880
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 123,520,880
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 123,520,88023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 6
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Wang Ming
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 1 0 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 203,758,500
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 203,758,500
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 203,758,500 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 203,758,500
15. NET INCOME FROM PREVIOUS PERIOD 15 529,731,290
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 733,489,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 733,489,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 198,056,040
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 141,203,160
21. PPh ARTICLE 21 PAYABLE 21 56,852,880
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 56,852,880
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 56,852,88023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 7
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Jacob, Anil
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Rig Supervisor PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 677,137,010
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 677,137,010
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 677,137,010 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 677,137,010
15. NET INCOME FROM PREVIOUS PERIOD 15
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 738,694,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 738,694,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 199,929,840
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 183,269,020
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 183,269,020
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 183,269,02023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)
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R1721 - A1 1. Sheet 1 for Employee2. Sheet 2 for Tax Witholder
.
MINISTRY OF FINANCE R.I.
2 0 1 3DIRECTORATE GENERAL OF TAXATION
SERIAL NO : 0 0 0 0 0 1 8
NPWP OF TAX WITHOLDER : 0 3 1 1 4 0 1 2 2 0 8 1 0 0 0
NAME OF TAX WITHOLDER : B U T C O S L B O S S L T DNAME OF EMPLOYEE OR PENSIONER : Reid, Nicholas
TAX PAYER NO. OF EMPLOYEE OR PENSIONER : 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ADDRESS OF EMPLOYEE OR PENSIONER : Prudential Tower 20th Fl Jl.Jend Sudirman Kav 79, Jakarta
STATUS, SEX AND EXPATRIATE : X MARRIED NOT MARRIED X MALE FEMALE X EXPATRIATE
FAMILY DEPENDENT FOR NON TAXABLE INCOME : K / 0 TK/ HB/
OCCUPATION : Crew PERIOD OF INCOME GENERATION 0 2 TO 1 2
A. DETAIL INCOME AND CALCULATION OF PPh ARTICLE 21 AS FOLLOW: RUPIAH
• GROSS INCOME:
1. SALARY/PENSION OR THT / JHT (RETIREMENT MONEY) 1 376,897,015
2. PPh (INCOME TAX) ALLOWANCE 2 0
3. OTHER ALLOWANCES, OVERTIME PAY, ETC 3 0
4. FEE AND OTHER REMUNERATION LIKEWISE 4 0
5. INSURANCE PAYMENT PAID BY EMPLOYER 5 0
6. RECEIVE IN NATURAL FORM AND OTHER BENEFIT AS IMPOSED BY PPh ARTICLE 21 6 0
7. TOTAL(1 to 6) 7 376,897,015
8. TANTIEM, BONUS, GRATIFICATION, PRODUCTION SERVICE AND HOLIDAY ALLOWANCES 8 0
9. TOTAL GROSS INCOME (7 + 8) 9 376,897,015 • DEDUCTION:
10. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 7 10 0
11. JOB/PENSION EXPENSES AGAINST INCOME MENTIONED ON NUMBER 8 11 0
12. PENSION OR HOLIDAY ALLOWANCES PREMIUM 12 0
13. TOTAL DEDUCTION (10 + 11 + 12) 13 0• CALCULATION OF PPh ARTICLE 21 :
14. TOTAL NET INCOME (9 - 13) 14 376,897,015
15. NET INCOME FROM PREVIOUS PERIOD 15 0
16. TOTAL NET INCOME FOR CALCULATION PPh ARTICLE 21 (ONE YEAR) 16 411,160,000
17. 17 0
18. TAXABLE INCOME FOR ONE YEAR PERIOD(16 - 17) 18 411,160,000
19. PPh ARTICLE 21 AGAINST TAXABLE INCOME FOR ONE YEAR19 87,348,000
20. PPh ARTICLE 21 AFTER DEDUCTED BY PREVIOUS PERIOD 20 0
21. PPh ARTICLE 21 PAYABLE 21 80,069,000
22. PPh ARTICLE 21 AND ARTICLE 26 ALREADY WITHOLDED AND PAID 22 80,069,000
22a Witholded and paid by SSP PPh Article 21 by Government22a 0
22b Witholded and paid by SSP (Tax Payment Slip) 22b 80,069,00023 TOTAL PPh ARTICLE 21 :
X a. UNDERPAYMENT (21-22)23 0
b. OVERPAYMENT (21-22)
24 TOTAL ON NUMBER 23 HAS BEEN:
X a. WITHELD FROM SALARY PAYMENT MONTH YEAR 24 0
b. CALCULATED WITH PPh ARTICLE 21 MONTH YEAR
B. COMPANY STAMP&AUTHORIZED SIGNATORY JAKARTA 3 1 1 2 2 0 1 3
X TAX WITHOLDER PROXY (Place) DATE ` MONTH YEAR
COMPANY STAMP&AUTHORIZED SIGNATORY
FULL NAME IAN STRACHAN STAMPED & SIGNED
TAX PAYER NO. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (BUT COSL BOSS LTD)
IN CASE THIS FORM NOT SUFFICIENT, SELF MADE FOLLOWING THIS FORMAT
This is translated from Indonesian to English by Certified Translator duly authorized by the Governor Decree of Jakarta Capital City Province No.269/1981
TAX WITHOLDING RECEIPT OF PPh (INCOME TAX) ARTICLE 21 FOR EMPLOYEE, PENSIONER OR RETIREMENT/OLD AGE SAVING
NON TAXABLE INCOME (PENGHASILAN TIDAK KENA PAJAK/PTKP)