Lampiran : SE-01/PJ.10/1994
Tanggal   :                     ,19........

..................................19...............(1)

TO WHOM IT MAY CONCERN
NO. :.............................................(2)

Head of District Tax Office..............................................................................…..............................(3) certify that :
Name of Taxpayer	:	................................................................................................................(4)
Identification Number	:	.................................................................................................................(5)
Address	:	.................................................................................................................(6)
is a resident of Indonesia for indonesian tax purposes.

DIREKTOR GENERAL OF TAXATION

HEAD OF DISTRICT TAX OFFICE

.......................................................(7)

.......................................................(8)

(10)

.......................................................(9)

NIP.

PETUNJUK PENGISIAN

(1)	Tempat, tanggal dan tahun penerbitan
(2)	Nomor surat;
(3)	Nama Kantor Pelayanan Pajak;
(4)	Nama lengkap Wajib Pajak;
(5)	Nomor Pokok Wajib Pajak;
(6)	Alamat Wajib Pajak;
(7)	Nama Kantor Pelayanan Pajak;
(8)	Tanda tangan;
(9)	Nama dan NIP Kepala Pelayanan Pajak;
(10)	Cap Kantor