FOR TAXPAYER WHO HAVE INCOME:
• •
FROM ONE OR MORE EMPLOYER;
•
SUBJECTED TO FINAL ANDOR FINALIZED TAX; ANDOR
BOOKKEEPING RECORDING
•
OTHER DOMESTIC INCOMEFOREIGN INCOME.
STNDRDTH AMENDED RETURN
• •
PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
•
: TAXPAYERS NAME
: :
TELEPHONE FAX NUMBERS :
: KK
HB PH
MT SPOUSES TIN
:
1. 1
2. 2
3. 3
4. OFFSHORE 4
5. 5
…………………………………………………………………………………………………………………………..
6 7. TOTAL NET INCOME AFTER ZAKATCOMPULSORY RELIGIOUS DONATION 5 - 6
8. 8
9. 9
10. PERSONAL EXEMPTIONS
TK K
K I
10 11.
11 12. INCOME
14 15.
15 16.
a.
TAX DUE AFTER CREDIT
b.
TAX OVERLY WITHHELD
17. a.
17a b.
17b 18.
18 a.
UNDERPAID TAX INCOME TAX ARTICLE 29
b.
OVERPAID TAX INCOME TAX ARTICLE 28 A
20.
REQUEST: Overpaid amount stated in 19.b would be
THE AMOUNT IS CALCULATED BY:
a.
112 X THE TOTAL OF LINE 16
c.
CALCULATION IN SEPARATE ATTACHMENT
b.
CALCULATION OF INDIVIDUAL TAXPAYER AS CERTAIN ENTERPRENEUR
OTHER THAN FORM OF 1770 - I TO 1770 - IV WHETHER FILLED OR THAT ARE NOT FILLED WITH THIS ALSO ATTACHED:
a.
POWER OF ATTORNEY IF NEEDED
g. b.
THIRD COPY OF TAX PAYMENT SLIP OF INCOME TAX ARTICLE 29
h. c.
i.
d.
CALCULATION OF FISCAL LOSS CARRY FORWARD
j. e.
k. f.
COPY OF FORM 1721-A1 ANDOR 1721-A2 Pages
l.
TAXPAYER PROXY
F.1.1.32.16
D . T
A X
C R
ED IT
PREPAID TAX: TAX LIABILITY STATUS OF MARRIED
INDIVIDUAL
to
21. MONTHLY INSTALLMENT FOR THE SUBSEQUENT YEAR TAXABLE INCOME
9 -10
The filing columns of Rupiah value must be without decimal value see example in page 3 of instructions
NET INCOME
[Complete it from separate attachment, if any foreign income, see instruction book]
TAX PAYABLE TAX RATE ON ARTICLE 17 X LINE 11
[For Taxpayers with status PHMT filled from Attachment Calculation of Income Tax Payable as referred to in Section G: Attachments letter i]
C . T
A X
PA YA
B LE
B . T
A XA
B LE
IN C
O M
E TOTAL NET INCOME AFTER LOSS CARRY FORWARD
7 - 8
TOTAL TAX CREDIT 17a+17b
13.
TOTAL NET INCOME 1 + 2 + 3 + 4
NOTICES OF TAX COLLECTION ON INCOME TAX ARTICLE 25 PRINCIPAL ONLY
16
14-15
c.
RECEIPTS OF WITHHOLDING TAXTAX BORNED BY THE GOVERNMENTTAX PAID AND WITHHELD IN FOREIGN
a.
REFUNDED WITH SKPPKP ARTICLE 17 C COMPLIANCE TAXPAYER
REFUNDED WITH SKPPKP ARTICLE 17 D TAXPAYER WHICH MEETS CERTAIN
REQUIREMENTS
d.
MONTHLY INSTALLMENT OF INCOME TAX ARTICLE 25
LIST OF INCOME AND PAYMENT OF INCOME TAX ARTICLE 25 ONLY FOR INDIVIDUAL TAXPAYER AS CERTAIN ENTERPRENEUR
16-18
BALANCE SHEET AND INCOME STATEMENT, OR RECAPITULATION OF MONTHLY GROSS REVENUE REFUNDED
LIST OF TOTAL GROSS INCOME AND FINAL TAX PAYMENT BASED ON GR 462013 FOR EACH TAX PERIOD AND PLACE OF BUSINESS
OF THE REPUBLIC OF INDONESIA
ID EN
TI TY
FROM BUSINESS ACTIVITYINDEPENDENT PERSONAL SERVICES;
YY
FO R
ATTENTION: FOLLOW INSTRUCTION IN THE INSTRUCTION BOOK
DIRECTORATE GENERAL OF TAXES
BUSINESS FIELD CLASSIFICATION INDEPENDENT PERSONAL SERVICE
TAXPAYER IDENTIFICATION NUMBER TIN
INCOME TAX CALCULATION FOR MARRIED TAXPAYER WITH SEPARATION OF PROPERTY AND INCOME PH OR HAS HER OWN TIN MT
21 b.
7
TAX WITHHELD BY OTHER PARTY, PAID WITHHELD IN FOREIGN AND BORNED BY THE GOVERNMENT [From Form 1770 -II Total Part A column 7]
MM
13
LOSS CARRY FORWARD OTHER DOMESTIC NET INCOME
[From Form 1770 - I page 2 Total Part D column 3]
DOMESTIC NET INCOME IN RESPECT OF EMPLOYMENT
[From Form 1770 - I page 2 Total Part C column 5]
MM
MINISTRY OF FINANCE
A . N
ET IN
C O
M E
YY
Data changes application submitted apart from this Tax Return, by using the Taxpayer Data Change Form and attached with the required documents.
TIN :
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 circumtances whatsoever.
E. IN
C O
ME T
A X
O VE
R U
N D
ER P
A ID
19.
DATE: 19
dd mm
SETTLED ON
SIGNATURE
DECLARATION
FULL NAME :
F. M
O N
TH LY
IN ST
A LL
M EN
T O
F
IN C
O ME
T A
X A
R TI
C LE
25 F
O R
T H
E SU
B SE
Q U
EN T
YE A
R
G .
A TT
A C
H M
EN TS
yy
DOMESTIC NET INCOME FROM BUSINESS ACTIVITIES ANDOR INDEPENDENT PERSONAL SERVICE
[From Form 1770 - I page 1 total part A or Form 1770 - I page 2 Total Part B column 5]
ADJUSTMENT FOR FOREIGN TAX CREDITS REFUNDED AND HAD BEEN CREDITED IN THE PREVIOUS YEAR RETURN Income Tax Article 24
COMPENSATED WITH OUTSTANDING TAX PAYABLE
CALCULATION OF INSTALLMENT OF INCOME TAX ARTICLE 25 FOR THE SUBSEQUENT YEAR
APPROPRIATE BOX MARK X IN THE
TA XA
B LE
Y EA
KLU :
RUPIAH
6. ZAKATCOMPULSORY RELIGIOUS DONATION
14. TOTAL INCOME TAX PAYABLE 12 + 13
to
BOOKKEEPING RECORDING
• •
PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
•
TIN
:
TAXPAYERS NAME
: DOMESTIC NET INCOME FROM BUSINESS ACTIVITIES ANDOR INDEPENDENT PERSONAL SERVICE
: AUDITED
ACCOUNTANT OPINION: UNAUDITED
NAME OF PUBLIC ACCOUNTANT :
TIN OF PUBLIC ACCOUNTANT :
NAME OF CPA :
TIN OF CPA :
NAME OF TAX CONSULTANT :
TIN OF TAX CONSULTANT :
NAME OF TAX CONSULTING FIRM
:
TIN OF TAX CONSULTING FIRM
:
a.
1a
b.
1b
c.
1c
d.
1d
e.
1e 2.
a.
2a
b.
2b
c.
2c
d.
2d
e.
2e
f.
2f
g.
2g
h.
2h
i.
2i
j.
2j
k.
2k
l.
2l
a.
3a
b.
3b
c.
3c
d.
3d 4
4
Copy total part A line 4 to Form 1770 line 1
OF THE REPUBLIC OF INDONESIA DIRECTORATE GENERAL OF TAXES
TA XA
B LE
YEA R
MM
YY
CALCULATION OF DOMESTIC NET INCOME FROM BUSINESS ACTIVITIES ANDOR INDEPENDENT PERSONAL SERVICE FOR TAXPAYER APPLYING
BOOKKEEPING SYSTEM
YY
GROSS INCOME
RUPIAH ATTENTION:
MARK X IN THE
1.
INCOME FROM BUSINESS ACTIVITIES ANDOR INDEPENDENT PERSONAL SERVICE BASED ON COMMERCIAL FINANCIAL STATEMENT:
PART A: FOR TAXPAYER APPLYING BOOKKEEPING SYSTEM
APPROPRIATE BOX FOLLOW INSTRUCTION IN THE INSTRUCTION BOOK
MM
ADMINISTRATIVE PENALTY POSSITIVE DIFFERENCE OF COMMERCIAL OVER FISCAL DEPRECIATIONAMORTIZATION
EXPENSES TO EARN, TO COLLECT AND SECURE INCOME SUBJECT TO FINALIZED INCOME TAX AND NON TAXABLE INCOME
OTHERS POSITIVE FISCAL ADJUSTMENT TOTAL 2a to 2k
INCOME SUBJECT TO FINAL WITHHOLDING TAX AND NON TAXABLE INCOME BUT INCLUDED IN GROSS INCOME
TOTAL 3a to 3c
TOTAL PART A 1e + 2l - 3d
NEGATIVE DIFFERENCE OF COMMERCIAL OVER FISCAL DEPRECIATIONAMORTIZATION COST OF GOOD SOLD
OPERATING INCOME 1a - 1b
POSITIVE FISCAL ADJUSTMENTS
COST INCURRED FOR THE PERSONAL BENEFIT OF A TAXPAYER OR HIS DEPENDENTS OPERATING EXPENSE
3.
NEGATIVE FISCAL ADJUSTMENT:
GIFTS, AID AND DONATIONS INSURANCE PREMIUMS FOR HEALTH, ACCIDENT, LIFE, DUAL PURPOSE AND EDUCATION
INSURANCE WHICH ARE PAID BY AN INDIVIDUAL TAXPAYER CONSIDERATION OR REMUNERATION RELATED TO EMPLOYMENT OR SERVICES GIVEN IN THE
FORM OF BENEFIT IN KIND
INCOME TAX
OTHERS NEGATIVE FISCAL ADJUSTMENT SALARIES PAID TO BUSINESS OWNERTAXPAYERS DEPENDENT
EXCESSIVE COMPENSATIONAM PAID TO ASSOCIATED PARTIES AS A CONSIDERATION OF WORK PERFORMED
NET INCOME 1c - 1d
BOOKKEEPING SYSTEM FINANCIAL STATEMENT
FO R
MINISTRY OF FINANCE
•
to
• •
CALCULATION OF OTHER DOMESTIC INCOME
BOOKKEEPING RECORDING
ATTENTION:
• •
PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
•
TIN
:
TAXPAYERS NAME
: PART B:
DOMESTIC NET INCOME FROM BUSINESS ACTIVITIES ANDOR INDEPENDENT PERSONAL SERVICE
Copy Total Part B column 5 to Form 1770 line 1
PART C : DOMESTIC NET INCOME IN RESPECT OF EMPLOYMENT
NOT INCLUDING INCOME SUBJECT TO FINALIZED INCOME TAX
Copy Total Part C Column 5 to Form 1770 line 2
PART D : OTHER DOMESTIC NET INCOMES
NOT INCLUDING INCOME SUBJECT TO FINALIZED INCOME TAX
Copy Total Part D to Form 1770 line 3
OF THE REPUBLIC OF INDONESIA
2
pages Page
from IF NEEDED, ADDITIONAL PAGES MAY BE ADDED
3 6
INTEREST
TOTAL PART D OTHER INCOMES
YY
TA XA
B LE
Y EA
MM YY
DIRECTORATE GENERAL OF TAXES
FOR TAXPAYER APPLYING RECORDING
3
MARK X IN THE APPROPRIATE BOX
CALCULATION OF DOMESTIC NET INCOME IN RESPECT OF EMPLOYMENT
CALCULATION OF DOMESTIC NET INCOME FROM BUSINESS ACTIVITIES ANDOR INDEPENDENT PERSONAL SERVICE FOR TAXPAYER APPLYING RECORDING
MM
1
FOLLOW INSTRUCTION IN THE INSTRUCTION BOOK
4
NO.
2
5
1
2
TYPES OF INCOME
3 4
5
1
RENT AWARDS AND PRIZES
TOTAL PART C
4 5
GROSS INCOME
4
NET INCOME Rupiah
NO. TRADING
INDUSTRY SERVICE
INDEPENDENT PERSONAL SERVICE
Rupiah NAME AND TIN OF EMPLOYER
NET INCOME Rupiah
TYPES OF BUSINESS DEEMED
GROSS INCOME Rupiah
TPB
3
2
NO.
2
DEDUCTION GROSS INCOMECOST
TPD GAIN FROM THE SALETRANSFER OF PROPERTY
ROYALTIES OTHERS
TOTAL PART B
1
5 6
1
1 3
4
FO R
MINISTRY OF FINANCE
Rupiah
2 5
TPC
3
TOTAL NET INCOME Rupiah
to
BOOKKEEPING RECORDING
ATTENTION:
• •
PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
•
TIN :
TAXPAYERS NAME :
PART A :
1
1 2
3 4
5 6
7 8
9 10
11 12
13 14
15 etc
-
=
-
Fill column 6 with following options: 2122232426DTP Example: 21, 22, 23, 24, 26, DTP
-
If there is a Tax Credit of Income Tax Article 24, the column should be filled with maximum creditable amount according to separate attachment Follow the Instruction related to Part A of Attachment II and Annual Tax Return line 4
from
pages of Attachment-II
FOLLOW INSTRUCTION IN THE INSTRUCTION BOOK
Page
IF NEEDED, ADDITIONAL PAGES MAY BE ADDED TPA
DTP
TOTAL PART A
Copy Total Part A Column 7 to Formulir 1770 line 15 BORNE BY THE GOVERNMENT
2 3
NO NAME OF WITHHOLDING
AGENT
LIST OF INCOME TAX WITHHELD BY OTHER PARTIES, PAIDWITHHELD IN FOREIGN AND BORNE BY THE GOVERNMENT
APPROPRIATE BOX DIRECTORATE GENERAL OF TAXES
MM
WITHHOLDING TAX RECEIPT DATE
TOTAL OF INCOME TAX WITHHELD Rupiah
TYPES OF TAX : INCOME TAX ARTICLE
2122232426DTP TIN OF WITHHOLDING
AGENT
LIST OF INCOME TAX WITHHELD BY OTHER PARTY, PAIDWITHHELD IN FOREIGN AND BORNED BY THE GOVERNMENT
TA XA
B LE
Y EA
YY MM
NUMBER
7 6
4 5
MARK X IN THE
YY
FO R
MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA
•
to
• •
BOOKKEEPING RECORDING
ATTENTION:
• •
PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
•
TIN
:
TAXPAYERS NAME
: PART A :
NO
1
1. 2.
