TAXABLE YEAR
TIN
:
TAXPAYERS NAME
: I.
ELEMENTS FROM BALANCE SHEET NO.
NO.
1. CASH AND EQUIVALENT 1. ACCOUNT PAYABLE - THIRD PARTY
2. TEMPORARY INVESTMENT 2.
3. ACCOUNT RECEIVABLE - THIRD PARTIES 3. INTEREST PAYABLE
4. 4. INTEREST TAXES
5. OTHER ACCOUNT RECEIVABLE - THIRD PARTIES 5. DIVIDEND PAYABLE
6. 6. ACCRUED EXPENSES
7. ALLOWANCE FOR DOUBTFUL ACCOUNTS 7. BANK PAYABLES
8. INVENTORIES 8.
9. PREPAID EXPENSES 9. ADVANCES
10. PURCHASING DOWN PAYMENT 10. OTHER CURRENT LIABILITIES
11. OTHER CURRENT ASSETS 11. LONG - TERM DEBT-BANK LOANS
12. LONG - TERM RECEIVABLE 12.
13. LAND AND BUILDING 13.
14. OTHER FIXED ASSETS 14. DEFERRED TAX LIABILITIES
15. ACCUMULATED DEPRECIATION 15. OTHER NON CURRENT LIABILITIES
16. INVESTMENT IN ASSOCIATION COMPANIES 16. CAPITAL STOCK
17. OTHER LONG - TERM INVESTMENTS 17.
18. INTANGIBLE ASSETS 18.
19. DEFERRED TAX ASSETS 19. RETAINED EARNINGS
20. OTHER NON CURRENT ASSETS 20. OTHER EQUITY
TOTAL ASSETS
II. ELEMENTS FROM INCOME STATEMENT NO.
1. NET SALES 2. BEGINNING INVENTORY
3. PURCHASE 4. ENDING INVENTORY
5. COST OF GOOD SOLD 2 + 3 - 4 6. GROSS PROFIT 1 - 5
7. SALES EXPENSE 8. GENERAL AND ADMINISTRATION EXPENSE
9. PROFIT 6 - 7 - 8 10. INCOME EXPENSE OTHER
11. NET EARNINGS FROM ASSOCIATES 12. INCOME BEFORE INCOME TAX 9 + 10 + 11
13. INCOME TAX BENEFIT EXPENSE 14. GAIN LOSS FROM NORMAL ACTIVITIES 12 - 13
15. EXTRAORDINARY ITEMS 16. GAINLOSS BEFORE MINORITY INTEREST 14 + 15
17. MINORITY INTEREST IN NET EARNING OF SUBSIDIARIES 18. NET PROFIT 16 - 17
III. TRANSACTION WITH RELATED PARTIES UNDER FINANCIAL ACCOUNTING STANDARD GUIDELINES PSAK NUMBER 7 NO.
2
a.
….…………………………………,
Place
b.
TAXPAYER AUTHORIZEDREPRESENTATIVE
c.
FULL NAME OF MANAGEMENTREPRESENTATIVE
PARTIES TYPES OF TRANSACTION
TRANSACTION VALUE IDR
LONG - TERM DEBT-THIRD PARTIES
DECLARATION
date month
year
d. Signature and Company Seal
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.
LONG -TERM DEBT-RELATED PARTIES LONG - TERM DEBTS-CURRENT MATURITIES
ACCOUNT RECEIVABLE - RELATED PARTIES OTHER RECEIVABLE WITH RELATED PARTIES
DESCRIPTION VALUE IDR
VALUE IDR
ACCOUNT PAYABLE - RELATED PARTIES
ADDITIONAL PAID-IN CAPITAL RETAINED EARNING FROM PREVIOUS YEAR
TOTAL LIABILITY AND OWNERS EQUITY
DESCRIPTION VALUE IDR
DESCRIPTION
2
TRANSCRIPT OF ELEMENTS CITATION OF FINANCIAL STATEMENT
TIN
:
TAXPAYERS NAME
: I.
ELEMENT FROM BALANCE SHEET NO.
NO.
INVESTMENT Acquisition Cost 1. ACTUARIAL LIABILITIES
1. DEPOSIT ON CALL 2.
2. TIME DEPOSIT NON ACTUARIAL LIABILITIES
3. 3. MATURE PENSION BENEFIT DEBTS
4. CERTIFICATES OF CENTRAL BANK 4. INVESTMENT PAYABLE
5. 5. PREPAID INCOME
6. BOND 6. ACCRUED EXPENSE
7. INVESTMENT IN MUTUAL FUND UNIT 7.
8. GOVERNMENT SECURITIES 9. COLLECTIVE INVESTMENT UNIT
10. DIRECT PLACEMENT 11. LETTER OF DEBT
12. LAND AND BUILDING Net 13. OTHER ALLOWED INVESTMENT
14. DIFFRENCE ON INVESTMENT CURRENT ASSETS NON INVESTMENT CURRENT ASSETS
15. CASH AND BANK 16. CONTRIBUTIONS - NORMAL EMPLOYEE
17. CONTRIBUTIONS - NORMAL PARTICIPANT 18. CONTRIBUTIONS - ADDITIONAL PARTICIPANT
19. LATE PREMIUM INTEREST RECEIVABLE 20. PREPAID EXPENSE
21. INVESTMENT RECEIVABLE 22. INVESTMENT REVENUE RECEIVABLE
23. OTHER RECEIVABLE OPERATING ASSETS
24. LAND AND BUILDING Net 25. OTHER OPERATING ASSETS Net
TOTAL ASSETS
II. ELEMENT FROM INCOME STATEMENT NO.
