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INCOME TAX WITHHOLDING


ART. 21 FOR EMPLOYEE OR
RECIPIENTS OF PENSION OR RETIREMENT FORM 1721 - A1
ALLOWANCE AND First Page: for Income Recipient
RETIREMENT SAVING Second Page: For Withholder

INCOME RECEIPT
MINISTRY OF FINANCE OF RI PERIOD [mm - mm]
DIRECTORATE GENERAL OF TAXES NO : H.01 1 . 1 - . - H.02 -

TIN OF
WITHHOLDER : H.03
- .
NAME OF
WITHHOLDER : H.04

A. IDENTITY OF WITHHELD INCOME RECIPIENT

1. TIN : A.01 - . 6. STATUS / NUMBER OF DEPENDANT

ID NO/ M/ S/ HB /
2. PASSPORT
NO. : A.02 A.07 A.08 A.09

3. NAME : A.03 7. OCCUPATION A.10

4. ADDRESS : A.04 8. FOREIGNER A.11 YES

9. DOMICILE COUNTRY CODE : A.12

5. SEX A.05 MALE A.06 FEMALE

B. DETAIL OF INCOME AND CALCULATION OF INCOME TAX ART. 21


DESCRIPTION AMOUNT (Rp)

TAX OBJECT CODE : 21-100-01 21-100-02

GROSS INCOME :

1. SALARY/PENSION/RETIREMENT ALLOWANCE

2. INCOME TAX ALLOWANCE

3. OTHER ALLOWANCE, OVERTIME ALLOWANCE, ETC

4. HONORARIUM AND OTHER SIMILAR INCOME

5. INSURANCE PREMIUM PAID BY THE EMPLOYER

6. INCOME IN THE FORM OF BENEFIT IN KIND OR OTHER WHICH WITHHELD BY INCOME TAX ART. 21

7. BONUS, GRATIFICATION, PRODUCTION SERVICE AND GRATIFIKASI

8. TOTAL GROSS INCOME (1 TO 7)

DEDUCTION :

9. OCCUPATIONAL DEDUCTION / PENSION EXPENSE

10. PENSION CONTRIBUTION OR RETIREMENT CONTRIBUTION

11. TOTAL DEDUCTION (9 TO 10)

INCOME TAX ART 21 CALCULATION :

12. TOTAL NET INCOME (8-11)

13. PREVIOUS PERIOD NET INCOME

14. TOTAL NET INCOME FOR INCOME TAX ART 21 CALCULATION (ANNUAL / ANNUALIZED)

15. PERSONAL EXEMPTION

16. ANNUAL / ANNUALIZED TAXABLE INCOME (14 - 15)


17. INCOME TAX ART. 21 OF ANNUAL / ANNUALIZED INCOME

18. INCOME TAX ART. 21 WHICH ALREADY WITHHELD IN THE PREVIOUS PERIOD

19. INCOME TAX ART 21 PAYABLE

20. INCOME TAX ART 21 AND ART 26 WHICH ALREADY BEEN WITHHELD AND SETTLED

C. IDENTITY OF WITHHOLDER

1. TIN : C.01 - . 3. DATE & SIGN

2. NAME : C.02 C.03 - -


[dd - mm - yyyy]