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1. Sura! Permohonan mena" re#anan $RI %&orma! Form SMR

1. Sura! Permohonan mena" re#anan $RI %&orma! Form SMR '1(1)'1(1)  Aa Aa T"a#T"a# 2.

2. Sura! Pem*a+aanSura! Pem*a+aan#e,enaran#e,enaran o#umen *an- "+ana(+an-an" " a+a ma+era" %&orma! Form SMRo#umen *an- "+ana(+an-an" " a+a ma+era" %&orma! Form SMR 01-2)01-2)  Aa Aa T"a#T"a# /0 Sura! Pem*a+aan !"a# a"2"+

/0 Sura! Pem*a+aan !"a# a"2"+ *an- "+ana(+an3an*an- "+ana(+an3an" " a+a " " a+a ma!era" %Forma+ Form SMR ma!era" %Forma+ Form SMR '1(/)'1(/)  Aa Aa T"a#T"a#

4, Company

4, Company Pro&"2e eua"Pro&"2e eua"ketentuanketentuan  Aa Aa T"a#T"a# 4

4. . SSoo&&+ + CCoo* * aa##++a a eenn""rr""aan n eerruuaahhaaaan n %%##hhuuuu  uunn++uu# # PPTT0 0 ++eerrmmaauu# # oo##uummeen n eenn--eeaahhaannnn**aa)) AAaa T"a#T"a# 50 So&+

50 So&+ Co* a#+a uunan Co* a#+a uunan en-uru +era#h"r %#huu un+u# PT0 +ermau# o#umen en-eahann*a)en-uru +era#h"r %#huu un+u# PT0 +ermau# o#umen en-eahann*a)  Aa Aa T"a#T"a# 60 So&+ Co*

60 So&+ Co* a#+a uunan em"2"#a#+a uunan em"2"#.anarn.anarn  _{Aa Aa T"a#T"a#}

7. So&+ Co*

7. So&+ Co* KTP en-uru eruahaanKTP en-uru eruahaan %O"re#"%O"re#" aan n KKoomm""aarr"") ) **aann- - mmaa""h h ,,eennaa##uu AAaa T"a#T"a# 8

800SSoo&&++CCoo**TTOOPP **aann--mmaa""hh,,eerr++aa##uu.. AAaa TT""aa## 1'0

1'0 So&+ Co* SIUP an So&+ Co* SIUP an er""nan een" 2a"nn*a *an- ,er+aer""nan een" 2a"nn*a *an- ,er+a#u %IUT #huu PMA)#u %IUT #huu PMA)  Aa Aa T"a#T"a# 110 So&+ Co* SKOP a+au SITU a+au HO

110 So&+ Co* SKOP a+au SITU a+au HO %I9"n :an--uan) *an- ma"h ,er2a#u%I9"n :an--uan) *an- ma"h ,er2a#u  Aa Aa T"a#T"a# 12,

12, So&+ Co* Sura+ I"n Ke-"a+an Khuu *an-So&+ Co* Sura+ I"n Ke-"a+an Khuu *an- ,er1a#u %SIU;K,er1a#u %SIU;K IISIU;PTSIU;PT II I"nI"n Ops.Ops. Tena-a Kera)Tena-a Kera)  Aa Aa T"a#T"a# 1/0

1/0 So&+ Co* Nera<a an So&+ Co* Nera<a an Laoran La,a Ru-" = +ahun +era#h2r.Laoran La,a Ru-" = +ahun +era#h2r.  Aa Aa T"a#T"a#

1>0

1>0 So&+ Co* Re#en"n- Koran So&+ Co* Re#en"n- Koran a+au $u#u Ta,un-a+au $u#u Ta,un-an a+a nama an a+a nama Peruahaan " $an# $RIPeruahaan " $an# $RI  Aa Aa T"a#T"a# 140 So&+ Co* NP?P

140 So&+ Co* NP?P  Aa Aa T"a#T"a#

150

150So&+ Co* PKP *an- ,er2a#uSo&+ Co* PKP *an- ,er2a#u  Aa Aa T"a#T"a# 17.

17. Da++arDa++ar en-a2aman e#eraanen-a2aman e#eraan 22 +h +era#h"r+h +era#h"ran an o&+ <o*o&+ <o* 22 SPK SPK +era#h"r+era#h"r00  Aa Aa T"a#T"a# 170 So&+ Co* D

170 So&+ Co* D o#umen Penu#un- Ia"nn*ao#umen Penu#un- Ia"nn*a  Aa Aa T"a#T"a# I<a+a+an@

I<a+a+an@ _II

II

II

ITan--a2

Form SMR Form SMR _01-101-1

KOP

Form SMR Form SMR _01-201-2

KOP

KOP SURA

SURAT

T PERUSAHAAN

PERUSAHAAN

Nemer Nemer Lam"ran Lam"ran Per"ha2

Per"ha2 _{Permohonan Permohonan Mena" Mena" Re#anan Re#anan Pen*e"aPen*e"a} $aran-

$aran- ana+au ana+au ;aa;aaPT.PT. $an# Ra#*a+ $an# Ra#*a+ Inone"a %Perero) T,#. Inone"a %Perero) T,#. ;a#ar+a0 B ;a#ar+a0 _{B ='14='14} Keaa +h. Keaa +h. KepaJa

KepaJa Divis; Divis; Manajemen Manajemen Aktiva TetapAktiva Tetap anan Pen-aaan Proer+"

Pen-aaan Proer+" PT

PT.. $an# Ra# $an# Ra#*a+ Inone"a *a+ Inone"a %Perero) T,#.%Perero) T,#. 2(

2(

Den-an horma+0 Den-an horma+0 $erama

$erama "n" er#enan#an "n" er#enan#an #am" m#am" men-au#an en-au#an ermohonan ermohonan un+u# mena&+ar un+u# mena&+ar e,a-a" e,a-a" Re#anan Re#anan Pen*e"a Pen*e"a $aran- $aran-ana+au

ana+au ;aa;aa PT PT. $an# . $an# Ra#*a+ Inone"a %Perero) T,#. un+u# Ra#*a+ Inone"a %Perero) T,#. un+u# u, ,"an- u, ,"an- e#eraan e#eraan e,a-a" ,er"#u+@e,a-a" ,er"#u+@

1. 1. 2. 2. 3. 3. . .

s.

s.

$erama

$erama "n" #am"n" #am" 2am"r#an " 2am"r#an a+a(a+a a+a(a+a eruahaan an eruahaan an er*ara+an er*ara+an 2a"n 2a"n *an- *an- "er2u#an "er2u#an un+u# un+u# menu#un- menu#un-uu2an mena" re#anan.

uu2an mena" re#anan. Dem"#"an ermohonan

Dem"#"an ermohonan #am"0 #am"0 a+a a+a erha+"an erha+"an an an #eraaman*a "ama"##eraaman*a "ama"#an +er"ma an +er"ma #a"h.#a"h.

Horma+

Horma+ Kam"0Kam"0

Tema+0 ='14 Tema+0 ='14 PTCUD 0 PTCUD 0 P"m"nan Peruahaan0 P"m"nan Peruahaan0 -- ITOITO - !ap

- !apPe"#sa$aanPe"#sa$aan

Nama Nama ;a,a+an @ ;a,a+an @  B  B  Tin%asan& Tin%asan&

Form SMR 01-2 Form SMR 01-2

KOP

KOP SURA

SURAT

T PERUSAHAAN

PERUSAHAAN

SURAT PERNY

SURAT PERNYA

AT

TAAN

AAN KEASLI

KEASLIAN

AN

_DOKUMEN

_DOKUMEN



an- an- ,er+ana+an-an ,er+ana+an-an " ,a" ,aah "n"@ah "n"@ Nama Nama Peruahaan Peruahaan  A2ama+  A2ama+ ;a,a+an

;a,a+an @ @ %"ha# %"ha# *an- *an- ,erenan- ,erenan- mea#"2" mea#"2" eruahaan)eruahaan)

Den-an

Den-an "n" men*a+a#"n" men*a+a#an an ,aha @,aha @ 1.

1. Se2uruh o#umen Se2uruh o#umen *an- #am" 2am*an- #am" 2am"r#an "r#an +e2ah eua" +e2ah eua" en-an o#umen en-an o#umen a2"n*a a2"n*a an ah an ah menuru+ menuru+ #e+en+uan#e+en+uan an

an erunan-(unan-an erunan-(unan-an *an- *an- ,er2a#u.,er2a#u. =.

=. Aa,"2a "#emu"an Aa,"2a "#emu"an har" har" "#e+emu#an "#e+emu#an ,aha ,aha o#umen(o#umen o#umen(o#umen *an- *an- +e2ah #am" ,er"#an +e2ah #am" ,er"#an +"a# ,enar0+"a# ,enar0 ma#a #am" ,ere"a "#ena#an

ma#a #am" ,ere"a "#ena#an an#" an#" an "mau#an an "mau#an aa Da&+ar San#" aa Da&+ar San#" Peruahaan Peruahaan an a+au "#e2uar#anan a+au "#e2uar#an ar" Da&+ar Re-"+ra" Peruahaan.

ar" Da&+ar Re-"+ra" Peruahaan. Dem"#"an ura+ en*a+aan

Dem"#"an ura+ en*a+aan "n" #am"n" #am" ,ua+ e,enar(,enarn*a0 " ,ua+ e,enar(,enarn*a0 a2am #on"" eha+0 er+a a2am #on"" eha+0 er+a +"a# +"a# ,eraa " ,eraa " ,aah,aah +e#anan "ha# manaun u-a. A+a

+e#anan "ha# manaun u-a. A+a erha+"an erha+"an an an #eraaman*a "ama"#an +er"ma #eraaman*a "ama"#an +er"ma #a"h.#a"h.

Horma+ Kam"0 Horma+ Kam"0 T Teemmaa++00 ==''1144 PTCUD PTCUD 00 P"m"nan Peruahaan0 P"m"nan Peruahaan0 (( TIDTID ( <a

( <a PeruahaanPeruahaan

(( Ma+era"Ma+era" Nama Nama ;a,a+an @ ;a,a+an @  B  B  T"naan@ T"naan@ 1. Ar" 1. Ar"

Form SMR 01-3 Form SMR 01-3

KOP

KOP SURA

SURAT

T PERUSAHAAN

PERUSAHAAN

SURAT

SURAT PERNYA

PERNYATMN

TMN TIDAK

TIDAK P

PAILIT

AILIT



an- an- ,er+ana+an-an ,er+ana+an-an " ,aah "n"@" ,aah "n"@ Nama Nama Peruahaan Peruahaan  A2ama+  A2ama+ ;a,a+an

;a,a+an @ @ %"ha# %"ha# *an- *an- ,erenan- ,erenan- mea#"2" mea#"2" eruahaan)eruahaan)

Den-an

Den-an "n" "n" men*a+a#an men*a+a#an ,aha ,aha PT PT C C UD UD +"a# +"a# ean- ean- a2am a2am en-aaanen-aaan en-a"2an0 "n*a+a#an a"2"+0

en-a"2an0 "n*a+a#an a"2"+0

%an'ata#

%an'ata#

+"a# +"a# ean- ean- mena2an" mena2an" an#" an#" "ana."ana. Dem"#"an ura+ en*a+aan

Dem"#"an ura+ en*a+aan "n" #am"n" #am" ,ua+ e,enar(,enarn*a0 " ,ua+ e,enar(,enarn*a0 a2am #on"" eha+0 er+a a2am #on"" eha+0 er+a +"a# +"a# ,eraa " ,eraa " ,aah,aah +e#anan "ha# manaun u-a. A+a erha+"an an #eraaman*a "ama"#an +er"ma #a"h.

+e#anan "ha# manaun u-a. A+a erha+"an an #eraaman*a "ama"#an +er"ma #a"h.

Horma+

Horma+ Kam"0Kam"0 Tema+0 Tema+0 201(201( PTCUD PTCUD r r  P"m"nan Peruahaan0 P"m"nan Peruahaan0 - TTO - TTO

-- !ap Pe"#sa$aan!ap Pe"#sa$aan -- Mate"aiMate"ai Nama Nama ;a,a+an  ;a,a+an   B  B  T"naan@ T"naan@ 1. Ar" 1. Ar"