ANNUAL INDIVIDUAL
INCOME TAX RETURN
FOR INDIVIDUALS WHO DO NOT CONDUCT BUSINESS / INDEPENDENT WORK
FORM
1770 S
TAX YEAR :
FILL IN USING BLOCK / TYPED LETTERS MARK “X” IN APPROPRIATE (BOX)
FILL IN CORRECTLY, COMPLETELY AND CLEARLY ACCORDING TO THE GUIDELINES
TAX ID (N P W P) :
NAME OF TAXPAYER : ...
RESIDENCIAL ADDRESS : ...
...
CITY / POST CODE : ...
OCCUPATION : ... KLU : TELEPHONE / FAX : ...
IN RUPIAH
A. NET INCOME 1. DOMESTIC NET INCOME FROM EMPLOYMENT [BROUGHT FORWARD FROM ATTACHMENT
I OF FORM 1770S PART A TOTAL COLUMN (5)] ...
2. OTHER DOMESTIC NET INCOME [BROUGHT FORWARD FROM ATTACHMENT I OF FORM 1770 S PART B TOTAL COLUMN (5)]...
3. NET INCOME OVERSEAS (BROUGHT FORWARD FROM A SEPARATE
ATTACHMENT) ...
...
4. TOTAL NET INCOME ( 1+2+3 ) ...
B. TAXABLE 5. TITHE... ...
INCOME 6. NON TAXABLE INCOME (PTKP) ...
S /... M /... M/W/... ASSET
SPLIT /... LIVING APART /...
7. TOTAL ( 5 + 6 ) ... 8. TAXABLE INCOME ( 4 – 7 ) ...
C. INCOME TAX 9. INCOME TAX PAYABLE ( RATES PER ART. 17 OF INCOME TAX LAW x LETTER B NO.
8) ... PAYABLE 10. REFUND / DEDUCTION OF ART. 24 (OFFSHORE TAX CREDIT) WHICH HAS BEEN
CREDITED...
11. TOTAL INCOME TAX PAYABLE ( 9 + 10 ) ...
D. TAX CREDIT 12. INCOME TAX WITHHELD/COLLECTED BY OTHER PARTIES/BORNE BY GOV'T [BROUGHT
FORWARD FROM ATTACHMENT I OF FORM 1770 S PART C TOTAL COLUMN (5)] AND TAX PAID/WITHHELD/PAYABLE OVERSEAS (BROUGHT FORWARD FROM A SEPARATE ATTACHMENT) ...
13. a. INCOME TAX PAYABLE BY SELF
--- ( 11 – 12 ) ...
b. OVERWITHHELD/OVERCOLLECTED TAX
14. TAX PAID BY SELF
a. Art. 25 paragraph (1)... b. Art. 25 Tax Collection Notice (excluding penalties)...
c. FISCAL EXIT TAX... TOTAL TAX CREDIT ( a +b+c ) ...
E. UNDER / OVER 15. a. UNDERPAYMENT OF TAX (ART. 29 INCOME TAX)
PAYMENT OF --- ( 13 – 14 ) ….….
TAX b. OVERPAYMENT OF TAX (ART. 28A INCOME TAX)
AMOUNT STATED IN ITEM 15a HAS BEEN FULLY PAID ON...
DEPARTEMEN KEUANGAN RI DIREKTORAT JENDERAL PAJAK
F.1.1.32.18
F. REQUEST REQUEST FOR THE AMOUNT STATED IN ITEM 15b TO BE:
REFUNDED OFFSET AGAINST TAX PAYABLES
G. ART. 25 INSTALLMENT FOR THE FOLLOWING YEAR
ART. 25 INSTALLMENT FOR THE FOLLOWING YEAR...…….……. Rp.
THE AMOUNT IS CALCULATED BASED ON : a. 1/12 OF AMOUNT STATED IN ITEM 13 a
b. SEPARATE CALCULATION IS ATTACHED
H. INCOME SUBJECT
TO FINAL TAX AND SUBJECT TO SEPARATE TAX
TYPE OF INCOME TAX BASE / GROSS INCOME
(RUPIAH)
TAX (RUPIAH)
SUBJECT TO FINAL TAX
a. INTEREST ON TIME AND SAVING DEPOSITS...
b. INTEREST/DISCOUNT ON BONDS SOLD IN STOCK EXCHANGE AND DISCOUNTS ON BANK INDONESIA CERTIFICATE (SBI) ....
c. SALE VALUE OF SHARES SOLD IN STOCK EXCHANGE …..……
d. LOTTERY PRIZES ………..
e. LUMPSUM PAYMENT OF SEVERANCE, OLD AGE ALLOWANCE AND PENSION ...……….….……..……….
f. HONORARIUM PAID FROM STATE / REGIONAL BUDGET …...
g. TRANSFER VALUE OF LAND AND OR BUILDING ...……...
h. VALUE OF BUILDING RECEIVED FOR BUILD OPERATE TRANSFER (BOT) ...………...………....
i. RENTAL OF LAND AND/OR BUILDING ………....
j. OTHER INCOME SUBJECT TO FINAL TAX ..………...…
SUBJECT TO SEPARATE TAX
a. WIFE’S INCOME FROM ONE EMPLOYER ...……..…….
b. SON’S/DAUGHTER’S INCOME FROM WORK …..……….
TOTAL……
…...
I. NON TAXABLE
OBJECTS
GROSS INCOME (RUPIAH)
a. AID / DONATION / BESTOWED……...
b. INHERITANCE... c. PROFITS DISTRIBUTION FROM LIMITED PARTNERSIPS, PARTNERSHIPS, GROUPS, FIRMS,
JOINT COMPANIES………...
d. CLAIM OF HEALTH, ACCIDENT, LIFE, DUAL FUNCTION INSURANCE, SCHOLARSHIP...
e. OTHER NON TAXABLE INCOME………...
TOTAL ……...
J. ASSETS AND
LIABILITIES 1. TOTAL ASSETS [BROUGHT FORWARD FROM ATTACHMENT II OF FORM 1770 S PART A TOTAL COLUMN (4)]
Rp...
2. TOTAL LIABILITIES [BROUGHT FORWARD FROM ATTACHMENT II OF FORM 1770 S PART B TOTAL COLUMN (4)]
Rp...
K. ATTACHMENTS IN ADDITION TO ATTACHMENTS TO FORM 1770-S, THE FOLLOWING ARE ATTACHED:
a. COPY OF FORM 1721-A1 AND/OR 1721-A2
b. LIST OF DEPENDENT FAMILY MEMBERS
c. 3RD COPY OF ART. 29 INCOME TAX PAYMENT FORM
d. LIMITED POWER OF ATTORNEY (IF SO ASSIGNED)
e. ………..
L. STATEMENT I AM AWARE OF ALL THE CONSEQUENCES INCLUDING THE PENALTIES PER THE PREVAILING LAWS AND I HEREBY STATE THAT ALL INFORMATION AND ATTACHMENTS CONTAINED HEREIN ARE CORRECT, COMPLETE AND CLEAR.
………, ………..200 ……
TAX PAYER SIGNATURE :
PROXY FULL NAME :
