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Formulir Kiriman Uang

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PendudulV

Nama/Nome;

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z '
'rK.>l

ul??i'f??"

::.;

aubn Penduduk/

Jenis Pengiriman/

r\\t? feriff "u t,E rrA

Kotal City:

Bank Penerima

Nery,aral

:i

Nama/ Nome

fl

Country:

/ Beneflclary'^onk i ii.)

Mata Uang/ Currency:

ii4\,r-J

fiL,Fi'fl?T uLr

Nama Alias/A/los Nome;

No,
:
KT P I S I M / P assp o rt/ KITAS :

ffi

c"V

oraft

swrrr

BG No. .,,.,..,

fl

ton

Jumlah Dana yang dikirim/Amount Tronsfer

PLM t*iu{eqdfal.9ory4{.1,{o' l\ulf U*r-i

No. Rek/ Acc No. i lQ4 . {.i2- .f)4 . Dl4 6'[ . !
Pengirim/Remltfer ! penAuOut</ ! Auhn Penduduk/
oEW:'
Kota/ City

ILG/ (1ss1ing
RTGS f]fl

Sumber Dana/Source offund :

f] Tunai/ cosh
n
oeoit Rek./ DebtiAcc, No

Alamat/Address;
Telepon/ Phone:
t.

Type of Tronsfer

uso

fii

ID

Alamat/Address

Telepon/ Phone:
Kotal

City;

f,

fll'

Fr- p-

ft1d-IA

I'ulApt

"',"1i

Nqaral Country:

Tujuan Transaksi (Tronsoctlon Purpose) : ..,.,.....,.,.,.,..,

"
Biaya dari bank koresponden dibebankan ke rekening/
Correspondenl bonk chorees ore
- lor occount ol :

p"n"iirrla/

j.,.f.1:;;-'........,.'.

menyetujur sepenuhnya syara!syaral

tercantum pada halaman belakang
ini/ | unconditionally accept all the

sharins

F
t:

t,

U p;g'riml Ramitter I

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nf .{'K$jivr"

Peiabat Bank
kryule. otau btus laEa" yary bffiNng4tu
tpqkttu lm dl b r& n kare is a compdadr.a @lidatian ot the authcx2e stghatne
'IransaksiolehpndudokdiatasRp.lmjubwaiibmryisifsmPMN(KYCIlTlansaclonbyrcsdentznountingRp.lOOmillbnmusllillintheP2MN(KvC)Fonn
Transaksr oleh bukan ponduduk di alas USD)1O.m.rsukuMalonnyawajlbffingbifomLLOI/l@nsactionbynanresidehtamo!.ttngora'Us'tooaaatr'.t-rilt
USS
10.@ alau

Bank Officer

Penyetor

Sah ika ada cetakan dala

1O.oAD

n.|:1nI
rlt rn the LLD
at ils cautvatarl tnrst

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/ Applicont