C. Bentuk Form DGT-1 - 21

1 - 21 -C. Bentuk Form DGT-1 MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA DIRECTORATE GENERAL OF TAXESG uidance :This form is to be completed by a person (which includes a body of a person, corporate or non corporate) : who is a resident of a country which has concluded a Double Taxation Convention (DTC) with Indonesia; and Do not use this form for : a banking institution, or a pension fund, or NAME OF THE COUNTRY OF INCOME RECIPIENT :INCOME RECIPIENTTax ID Number:Name:Full address:Contact Number:(5)email :PART IIDECLARATION BY THE INCOME RECIPIENTI, (full name)herebydeclare that I have examined the information provided in this form and to the best of my knowledge and belief it is true, correct, and complete.

2 I further declare that I am this company is not an Indonesian resident (8),//(9)(10)PART IIICERTIFICATION BY COMPETENT AUTHORITY OR AUTHORIZED TAX OFFICE OF THE COUNTRY OF RESIDENCE:For the purpose of tax relief, it is hereby confirmed that the taxpayer mentioned in Part I is a resident infor the period(12)to(13)of the fiscal year(14)withinthe meaning of the Double Taxation Convention in accordance with Double Taxation Convention concluded between Indonesia and(15)(16)(17)//(18)Place, date (mm/dd/yy)Office address:(19) DGT-1 Page 1(4)(1)taxpayer.

3 (Please check the box accordingly)(7)(6)PART I(2)This form is available and may be downloaded at this website: in which actingName and Signature of the Competent Authority or his authorized representative or authorized tax officeCapacity/designation of signatorySignature of the income recipient or individual authorized to sign for the income recipientPlace, date (mm/dd/yy)(11)(FORM DGT-1 )CERTIFICATE OF DOMICILE OF NON RESIDENTFOR INDONESIA WITHHOLDING TAX (3)who claims relief from Indonesia IncomeTaxinrespectofthe following income earnedinIndonesia (dividend, interest,royalties, income from rendering services, and other income)

4 Subject to withholding tax in person who claims relief from Indonesia IncomeTaxinrespectofincome arises from the transferof bonds orstocks whichtradedorregisteredinIndonesia stock exchangeandearned the incomeorsettled the transaction through a CustodianinIndonesia, other than interest and the form aretobeproperly furnished,andthe form shallbesignedascompleted. This form mustbecertifiedbytheCompetent Authorityorhis authorized representativeorauthorized tax officeinthe country where the income recipientisa taxresident before submitted to Indonesian withholding Stamp (if any)PART IVINDONESIA WITHHOLDING AGENTTax ID Number:(20)Name:(21)Full address:(22)Contact Number :(23)email :(24)PART VTO BE COMPLETED IF THE INCOME RECIPIENT IS AN of Income Recipient :(25) of birth (mm/dd/yyyy)://(26) address.

5 (27) of the principal purposes of the arrangements or transactions is to obtain Yes No(28)benefit under the convention and contrary to the object and purpose of the DTC. you acting as an agent or a nominee? Yes No(29) you have permanent home in Indonesia? Yes No(30) what country do you ordinarily reside?(31) you ever been resided in Indonesia? Yes No(32)If so, in what period?//to//Please provide the address you have any office, or other place of business in Indonesia? Yes No(33)If so, please provide the address :PART VITO BE COMPLETED IF THE INCOME RECIPIENT IS NON of registration/incorporation :(34) country does the place of management or control reside?

6 (35) of Head Office :(36) of branches, offices, or other place of business in Indonesia (if any) :(37) of the principal purposes of the arrangements or transactions is to obtain Yes No(38)benefit under the convention and contrary to the object and purpose of the DTC. are relevant economic motives or other valid reasons for the Yes No(39)establishment of the foreign entity has its own management to conduct the business and Yes No(40)such management has an independent entity has sufficient assets to conduct business other than the assets Yes No(41) generating income from entity has sufficient and qualified personel to conduct the business.

7 Yes No(42) entity has business activity other than receiving dividend, interest, Yes No(43)royalty sourced from declare that I have examined the information provided in this form and to the best of my knowledge and belief it is true, correct, and complete.(44),//(45)(46) DGT-1 Page 2 This form is available and may be downloaded at this website: , date (mm/dd/yy)Signature of the income recipient or individual authorized to sign for the income recipientCapacity in which acting- 22 -PART VIITO BE COMPLETED IF THE INCOME EARNED ARE DIVIDEND, INTEREST, OR entity is acting as an agent, nominee or conduit Yes No(47) entity has controlling rights or disposal rights on the income Yes No(48)or the assets or rights that generate the more than 50 per cent of the entity's income is used to satisfy claims by Yes No(49)

8 Other entity bear the risk on its own asset, capital, or the liability Yes No(50) entity has contract/s which obliges the entity to transfer the income Yes No(51)received to resident of third VIIIINCOME EARNED FROM INDONESIA IN RESPECT TO WHICH RELIEF IS , Interest, or of Income :(52) of Income liable to withholding tax under Indonesian Law :IDR.(53) of Income liable to withholding tax under DTC :Amount :(54)Percentage :(55) from rendering services (including professional) of Income :(56) of Income liable to withholding tax under Indonesian Law :IDR.

9 (57) of Income liable to withholding tax under DTC :Amount :(58)Percentage :(59) of engagement (mm/dd/yy) :(60)//to////to////to//// Type of Income of Income :(61) of Income liable to withholding tax under Indonesian Law :IDR.(62) of Income liable to withholding tax under DTC :Amount :(63)Percentage :(64)I declare that I have examined the information provided in this form and to the best of my knowledge and belief it is true, correct, and complete.(65),//(66)(67)This form is available and may be downloaded at this website: of the income recipient or individual authorized to sign for the income recipientPlace, date (mm/dd/yy)Capacity in which actingDGT-1 Page 3