Name of Taxpayer

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 CLEARLYACCORDING 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......
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 / :

F.1.1.32.18