1721 A1 English Version 5g2y62

staples

area INCOME TAX WITHHOLDING ART. 21 FOR EMPLOYEE OR RECIPIENTS OF PENSION OR RETIREMENT ALLOWANCE AND RETIREMENT SAVING

FORM 1721 - A1 First Page: for Income Recipient Second Page: For Withholder INCOME RECEIPT

MINISTRY OF FINANCE OF RI DIRECTORATE GENERAL OF TAXES TIN OF WITHHOLDER

:

H.03

NAME OF WITHHOLDER

:

H.04

NO :

1

H.01

.

PERIOD [mm - mm]

1 -

-

.

-

-

H.02

.

A. IDENTITY OF WITHHELD INCOME RECIPIENT 1.

TIN

: A.01

2.

ID NO/ PORT NO.

: A.02

3.

NAME

: A.03

4.

ADDRESS : A.04

-

.

6. STATUS / NUMBER OF DEPENDANT M/

S/ A.07

7. OCCUPATION 8. FOREIGNER

HB / A.08

A.09

A.10 A.11

YES

9. DOMICILE COUNTRY CODE : A.12 5.

SEX

MALE

A.05

A.06

FEMALE

B. DETAIL OF INCOME AND CALCULATION OF INCOME TAX ART. 21 DESCRIPTION TAX OBJECT CODE

:

21-100-01

21-100-02

GROSS INCOME : 1.

SALARY/PENSION/RETIREMENT ALLOWANCE

2.

INCOME TAX ALLOWANCE

3.

OTHER ALLOWANCE, OVERTIME ALLOWANCE, ETC

4.

HONORARIUM AND OTHER SIMILAR INCOME

5.

INSURANCE PAID BY THE EMPLOYER

6.

INCOME IN THE FORM OF BENEFIT IN KIND OR OTHER WHICH WITHHELD BY INCOME TAX ART. 21

7.

BONUS, GRATIFICATION, PRODUCTION SERVICE AND GRATIFIKASI

8.

TOTAL GROSS INCOME (1 TO 7)

DEDUCTION : 9.

OCCUPATIONAL DEDUCTION / PENSION EXPENSE

10.

PENSION CONTRIBUTION OR RETIREMENT CONTRIBUTION

11.

TOTAL DEDUCTION (9 TO 10)

INCOME TAX ART 21 CALCULATION : 12.

TOTAL NET INCOME (8-11)

13.

PREVIOUS PERIOD NET INCOME

14.

TOTAL NET INCOME FOR INCOME TAX ART 21 CALCULATION (ANNUAL / ANNUALIZED)

15.

PERSONAL EXEMPTION

16. ANNUAL / ANNUALIZED TAXABLE INCOME (14 - 15)

AMOUNT (Rp)

17.

INCOME TAX ART. 21 OF ANNUAL / ANNUALIZED INCOME

18.

INCOME TAX ART. 21 WHICH ALREADY WITHHELD IN THE PREVIOUS PERIOD

19.

INCOME TAX ART 21 PAYABLE

20.

INCOME TAX ART 21 AND ART 26 WHICH ALREADY BEEN WITHHELD AND SETTLED

C. IDENTITY OF WITHHOLDER 1.

TIN

: C.01

2.

NAME

: C.02

-

.

3. DATE & SIGN C.03

[dd - mm - yyyy]

-