1770 INDIVIDUAL ANNUAL INCOME TAX RETURN 2 0

TAXABLE YEAR
FORM WITH INCOME:

to
FROM BUSINESS/SELF-EMPLOYMENT THAT IMPLEMENT ACCOUNTING OR
MINISTRY OF FINANCE DEEMED NET INCOME MM YY MM YY
DIRECTORATE GENERAL OF TAXES
FROM EMPLOYMENT FOR ONE OR MORE EMPLOYER(S) DEEMED ACCOUNTING
SUBJECT TO FINAL AND/OR FINALIZED TAX
FROM OTHER INCOME .. AMENDED RETURN
ATTENTION:
FOLLOW INSTRUCTION IN THE MANUAL
PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
MARK " X " IN THE APPROPRIATE BOX

TIN :
IDENTITY

TAXPAYER'S NAME :
BUSINESS CLASSIFICATION/SELF : KLU :
EMPLOYMENT
TELEPHONE /FAX NO : /

UP DATE OF IDENTITY : YES, SEPARATE ATTACHMENT NO

*) The filling columns of Rupiah value must be without decimal value (see example in instruction book page 3) IDR *)
1. DOMESTIC NET INCOME FROM BUSINESS AND/OR SELF EMPLOYMENT
[From Form 1770 - I page 1 total part A or Form 1770 - I page 2 Total Part B column 5]
1

2. DOMESTIC NET INCOME FROM EMPLOYMENT

[From Form 1770 - I page 2 Total Part C column 5]
2
A. NET INCOME

3. OTHER DOMESTIC NET INCOME

[From Form 1770 - I page 2 Total Part D column 3]
3
4. FOREIGN NET INCOME
[Complete it from separate attachment, if any foreign income, see instruction book]
4
5. TOTAL NET INCOME (LINE 1 + 2 + 3 + 4)
5
..
6. ZAKAT/OBLIGATED CHARITY
6

7. TOTAL NET INCOME AFTER ZAKAT/OBLIGATED CHARITY (LINE 5 - LINE 6)

7

8. LOSS CARRIED FORWARD

8
B. TAXABLE

9. TOTAL NET INCOME AFTER LOSS CARRIED FORWARD (LINE 7 - LINE 8)

INCOME

10. PERSONAL EXEMPTION TK/ K/ K/I/ PH/ HB/ 10

11. TAXABLE INCOME (LINE 9 - LINE 10)
11

12. TAX PAYABLE (TAX RATE ON ARTICLE 17 X LINE 11)

12
PAYABLE
C. TAX

13. ADJUSTMENT FOR FOREIGN TAX CREDITS REFUNDED AND HAD BEEN CREDITED IN THE PREVIOUS
YEAR RETURN (Income Tax Article 24)
13

14. TOTAL TAX PAYABLE ( LINE 12 + 13)

14

15. TAX WITHHELD BY OTHER PARTY/PAID /WITHHELD BY FOREIGN COUNTRIES AND BORNE BY THE
GOVERNMENT [From Form 1770 -II Total Part A column 7] 15

16. a. TAX DUE AFTER CREDIT

(14-15) 16
D. TAX CREDIT

b. TAX OVERLY WITHELD

17. PREPAID TAX: a. MONTHLY INSTALLMENT OF INCOME TAX ARTICLE 25

a

b. NOTICE OF TAX COLLECTION ON INCOME TAX ARTICLE 25 (PRINCIPAL ONLY)

b

c. INCOME TAX PAID ON THE DEPARTURE (FISCAL)

c

18. TOTAL TAX CREDIT (a+b+c)

18

SETTLED
19. a. UNDERPAID TAX (INCOME TAX ARTICLE 29)
OVER/UNDER PAID

(16-18) ON 19
E. INCOME TAX

b. OVERPAID TAX (INCOME TAX ARTICLE 28 A) DATE MONTH YEAR

20. REQUEST: Overpaid amount stated in 19.b would be a. REFUNDED c. REFUNDED WITH SKPPKP ARTICLE 17 C (COMPLIANCE TAXPAYER)

COMPENSATED WITH OUTSTANDING REFUNDED WITH SKPPKP ARTICLE 17 D (CERTAIN CRITERIA OF

b. TAX PAYABLE
d. TAXPAYER)
INCOME TAX ARTICLE 25
FOR THE SUBSEQUENT

21. MONTHLY INSTALLMENT FOR THE SUBSEQUENT YEAR 21

INSTALLMENT OF
F. MONTHLY

THE AMOUNT IS CALCULATED BY:

YEAR

a. 1/12 X THE TOTAL OF LINE 16 c. SEPARATE CALCULATION ATTACHED

b. CALCULATION OF PARTICULAR INDIVIDUAL TAXPAYER

OTHER THAN FORM OF 1770 - I TO 1770 - IV WITH THIS ALSO ATTACHED:

CALCULATION OF INSTALLMENT OF INCOME TAX ARTICLE 25 FOR THE SUBSEQUENT
a. POWER OF ATTORNEY (If needed) g.
ATTACHMENTS

YEAR

b. THIRD COPY OF TAX PAYMENT RECEIPT OF INCOME TAX ARTICLE 29 h. COPY OF RECEIPT OF INCOME TAX PAID ON THE DEPARTURE (FISCAL)

INCOME TAX CALCULATION FOR MARRIED TAXPAYER WITH SPLIT ESTATE AND/OR
c.
BALANCE SHEET AND INCOME STATEMENT, OR RECAPITULATION OF MONTHLY GROSS REVENUE i. HAS HER OWN TIN
G.

DETAILS OF INCOME AND PAYMENT OF INCOME TAX ARTICLE 25 (only for particular
d. CALCULATION OF TAX LOSS COMPENSATION j. Taxpayer)
RECEIPTS OF WITHHOLDING TAX/TAX BORNE BY THE GOVERNMENT/TAX PAID AND WITHELD IN FOREIGN
e. COUNTRY
k.
f. COPY OF FORM 1721-A1 AND/OR 1721-A2 (.Pages) l.
DECLARATION
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 SIGNATURE
true, complete, clear, and under no circumtances whatsoever

TAXPAYER REPRESENTATIVE DATE - -

FULL NAME

TIN

F.1.1.32.16