Lampiran I
SE-16/PJ.41/1990

DEPARTEMEN KEUANGAN REPUBLIK INDONESIA
DIREKTORAT JENDERAL PAJAK
_____________________________________

DAFTAR  ISIAN
QUESTIONAIRE

_______________________________________________________________________________________________

NAMA		:
NAME
KEWARGANEGARAAN		:
CITIZEN
PEKERJAAN		:
OCCUPATION
STATUS		:	Kawin/Tidak Kawin
STATUS			Married/      Single
TANGGUNGAN		:
FAMILY NUMBER
ALAMAT KANTOR		:
OFFICE ADDRESS
ALAMAT RUMAH		:
HOME ADDRESS
1.	Apakah Saudara menerima/memperoleh penghasilan di luar Indonesia Do you have any income emanated from outside Indonesia ?			:	............................................................  ............................................................  ............................................................  ............................................................
2	Apakah Saudara menerima/memperoleh penghasilan lain di Indonesia selain dari pekerjaan Saudara ? Do you have any income emanated from another job in Indonesia ?			:	............................................................  ............................................................  ............................................................  ............................................................
3	Jika Saudara kawin, apakah isteri Saudara mempunyai penghasilan sendiri di Indonesia maupun di luar Indonesia ? If you are married, does your wife have her own income in Indonesia and or ourside Indonesia ?			:	............................................................  ............................................................  ............................................................  ............................................................
4	Apakah Saudara berketetapan untuk menetap di Indonesia ? Do you have any intention to stay in Indonesia ?			:	............................................................  ............................................................  ............................................................  ............................................................

Dengan menyadari sepenuhnya segala akibat termasuk sanksi-sanksi perpajakan yang berlaku, saya telah mengisi daftar isian ini dengan sebenarnya

With fully awarenese to all causes including those tax sanetion presently in forse, I truthfully fulfill this form.

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Tanda tangan  :
Signature

Nama :
Name