VARIABEL Formulasi Perhitungan Pajak

Variabel Daerah Total Nilai

No NAMA Jenis Status Penambah Kinerja Insentif Jumlah diterima
Kehadiran Masa Kerja Beban A B C
Ketenagaan Kepegawaian Tugas Adm Kompetensi Pengurang PPh 21
Kerja
1 dr HENDRIYANTO.MARS 150 24 10 15.00 35 0 20 144 24 80.00 248.00 66,667 10,000 56,667

2 drg SRI ARIANI 150 19 10 8.00 25 0 5 114 19 48.00 181.00 48,656 2,433 46,223
3 dr.MUJIANTI.K 150 18 10 6.00 0 5 108 18 21.00 147.00 39,516 1,976 37,540
4 YANI GANESWATI 25 24 10 34.00 5 5 24 24 54.00 102.00 27,419 1,371 26,048
5 ENI ASTUTI 25 24 10 33.00 5 5 24 24 53.00 101.00 27,151 1,358 25,793
6 ROKANAH 40 25 10 32.00 5 5 40 25 52.00 117.00 31,452 1,573 29,879
7 ENOK ROSTIATIN 40 25 10 31.00 25 0 0 40 25 66.00 131.00 35,215 1,761 33,454
8 SUKAMI 40 25 10 28.00 5 0 40 25 43.00 108.00 29,032 1,452 27,581
9 DEDEH RUSTIAWATI 25 25 10 24.00 30 10 20 25 25 94.00 144.00 38,710 1,935 36,774
10 SRI SUSANTI 25 21 10 31.00 10 5 21 21 56.00 98.00 26,344 1,317 25,027
11 NURMINI 25 21 10 30.00 5 0 21 21 45.00 87.00 23,387 1,169 22,218
12 DJUANINGSIH 25 24 10 25.00 5 0 24 24 40.00 88.00 23,656 1,183 22,473
13 PUJI HARTATI 25 25 10 27.00 5 0 25 25 42.00 92.00 24,731 1,237 23,495
14 JOMANSEN PURBA 25 20 10 29.00 5 5 20 20 49.00 89.00 23,925 1,196 22,728
15 DINAH ROHMAWATI 15 21 10 32.00 5 0 12.6 21 47.00 80.60 21,667 21,667
16 MEGA ROBAENI 40 25 5 5.00 5 5 40 25 20.00 85.00 22,849 571 22,278
17 NENENG MARLINA.T 40 24 5 8.00 5 5 38.4 24 23.00 85.40 22,957 574 22,383
18 SITI AMINAH 38 23 5 9.00 5 5 34.96 23 24.00 81.96 22,032 551 21,481
19 NURUL.U.H 60 25 10 5.00 25 5 0 60 25 45.00 130.00 34,946 1,747 33,199
20 ELI HARYATI 40 25 10 14.00 5 5 40 25 34.00 99.00 26,613 26,613
21 AGUS TAMI 25 24 5 11.00 5 5 24 24 26.00 74.00 19,892 497 19,395
22 NANY.R 40 25 5 3.00 5 0 40 25 13.00 78.00 20,968 524 20,444
23 INDAH.P 40 24 5 7.00 5 0 38.4 24 17.00 79.40 21,344 534 20,810
24 KUSNADI 15 25 0 0.00 5 0 15 25 5.00 45.00 12,097 302 11,794
25 RAHMATULLOH 15 20 0 0.00 5 0 12 20 5.00 37.00 9,946 249 9,698
26 MILA 15 20 0 0.00 0 0 12 20 0.00 32.00 8,602 215 8,387
27 VELA YATI KESUMA 40 24 0 0.00 5 5 38.4 24 10.00 72.40 19,462 487 18,976
28 RATNA AMALIA 40 24 5 6.00 10 5 0 38.4 24 26.00 88.40 23,763 594 23,169

Jumlah 2801.16 753,000 36,805 716,195

susulan maret 2016

Cibinong, 11 Mei 2016
Kepala Puskesmas
 dr. HENDRIYANTO.MARS
NIP. 197011062001121005
 JASA PELAYANAN FKTP PUSKESMAS JAMPANG BULAN JANUARI 2017

Jmlh hari 25 Total Dana 54913000

BULAN : Januari 2017
VARIABEL Formulasi Perhitungan
Total Pajak
Persentase Rangkap Tanggung Penambah Sebelum PPH 21 TANDA
No NAMA Kehadiran Jenis Masa Kerja Tugas Point Jumlah diterima
Kehadiran (A) Adm Jawab Prog Pengurang
Ketenagaan (B) © ( G)
(D) (E) (F) (A X ( B+C+D+E+))/ XG PPh 21
TANGAN
1 dr,Vera Linda C.B 25 1.00 150 15.00 100.00 10.00 275.00 7,531,858 1,129,779 6,402,080 1.

2 dr.Rismaini 23 0.92 150 9.00 10.00 155.48 4,258,376 212,919 4,045,457 2.

3 Cucu Mariam 25 1.00 80 25.00 30.00 0.00 135.00 3,697,458 184,873 3,512,585 3.
4 Noli Haryono 25 1.00 60 25.00 0.00 85.00 2,328,029 116,401 2,211,628 4.
5 Ni nyoman suardi 25 1.00 80 25.00 10.00 115.00 3,149,686 157,484 2,992,202 5.
6 Kurniati 25 1.00 60 24.00 0.00 84.00 2,300,640 115,032 2,185,608 6.
7 Indrawati 25 1.00 80 23.00 0.00 103.00 2,821,023 141,051 2,679,972 7.
8 Siti Rogayah 24 0.96 80 23.00 50.00 0.00 146.88 4,022,834 201,142 3,821,692 8.
9 Arif Irsiyyadi 25 1.00 60 23.00 20.00 103.00 2,821,023 141,051 2,679,972 9.
10 Runi Khaerunisa 25 1.00 80 8.00 0.00 88.00 2,410,195 120,510 2,289,685 10.
11 Dewi Komala 0 - 60 5.00 10.00 0.00 - 0 0 11.
12 Lely Mauli 24 0.96 60 10.00 15.00 81.60 2,234,908 111,745 2,123,162 12.
13 Kasuhaevi 25 1.00 60 6.00 5.00 71.00 1,944,589 0 1,944,589 13.
14 Ismawati Diah 25 1.00 60 4.00 10.00 74.00 2,026,755 0 2,026,755 14.
15 Erna 0 - 60 5.00 0.00 0.00 - 0 0 15.
16 Musdalifah 25 1.00 60 0.00 10.00 70.00 1,917,200 0 1,917,200 16.
17 drg taufik 25 1.00 150 2.00 10.00 162.00 4,436,949 221,847 4,215,102 17.
18 rama yanti 25 1.00 60 6.00 10.00 76.00 2,081,532 104,077 1,977,455 18.
19 yanti Prihatin 25 1.00 60 10.00 0.00 70.00 1,917,200 95,860 1,821,340 19.
20 Ika 25 1.00 60 0.00 0.00 60.00 1,643,315 82,166 1,561,149 20.
21 Leny 25 1.00 25 0.00 0.00 25.00 684,714 41,083 643,632 21.
22 Deden A Mukti 25 1.00 25 0.00 0.00 25.00 684,714 41,083 643,632 22.

Jumlah 2004.96 54,913,000 3,218,103 51,694,897

Mengetahui/Menyetujui
Kepala UPF Puskesmas Jampang Bendahara JKN UPF Puskesmas Jampang

( dr.Vera Linda C.B ) ( Siti Rogayah )

NIP 196611182002122003 NIP 197112151992032003
 JASA PELAYANAN FKTP PUSKESMAS JAMPANG SUSULAN BULAN DESEMBER 2016

Jmlh hari 26 Total Dana 571000

BULAN : susulan Desember 2016
VARIABEL Formulasi Perhitungan
Pajak
Total
Persentase Tanggung Penambah Sebelum PPH 21 TANDA
No NAMA Kehadiran Kehadiran (A) Jenis Masa Kerja Rangkap Tugas Jawab Point Jumlah diterima
Prog Pengurang ( G)
Ketenagaan (B) © Adm (D) (A X ( B+C+D+E+))/ XG PPh 21
(E) (F)
TANGAN
1 dr,Vera Linda C.B 25 0.96 150 10.00 100.00 5.00 254.81 82,487 12,373 70,114

2 dr.Rismaini 24 0.92 150 5.00 143.08 46,317 2,316 44,002

3 Cucu Mariam 26 1.00 80 5.00 10.00 95.00 30,754 1,538 29,216
4 Noli Haryono 19 0.73 60 25.00 62.12 20,108 1,005 19,103
5 Ni nyoman suardi 26 1.00 80 25.00 10.00 115.00 37,228 1,861 35,367
6 Kurniati 26 1.00 60 25.00 85.00 27,517 4,127 23,389
7 Indrawati 25 0.96 80 25.00 10.00 110.58 35,796 1,790 34,007
8 Siti Rogayah 26 1.00 60 25.00 50.00 135.00 43,703 2,185 41,518
9 Arif Irsiyyadi 25 0.96 60 20.00 20.00 96.15 31,127 1,556 29,571
10 Runi Khaerunisa 22 0.85 60 25.00 71.92 23,283 1,164 22,119
11 Dewi Komala 0 - 60 25.00 10.00 0.00 - 0 0
12 Lely Mauli 19 0.73 60 20.00 10.00 65.77 21,291 1,065 20,227
13 Kasuhaevi 18 0.69 60 25.00 58.85 19,050 0 19,050
14 Ismawati Diah 20 0.77 60 25.00 10.00 73.08 23,657 0 23,657
15 Erna 0 - 60 25.00 0.00 - 0 0
16 Musdalifah 25 1.00 60 0.00 10.00 70.00 22,661 0 22,661
16 drg taufik 26 1.00 60 5.00 65.00 21,042 1,052 19,990
17 rama yanti 26 1.00 60 5.00 65.00 21,042 1,052 19,990
18 yanti Prihatin 26 1.00 60 5.00 65.00 21,042 1,052 19,990
19 Ika 25 0.96 60 5.00 62.50 20,233 1,012 19,221
20 Leny 26 1.00 25 10.00 35.00 11,330 680 10,651
21 Deden A Mukti 26 1.00 25 10.00 35.00 11,330 680 10,651

Jumlah 1763.85 571,000 36,509 534,491

Mengetahui/Menyetujui
Kepala UPF Puskesmas Jampang Bendahara JKN UPF Puskesmas Jampang

( dr.Vera Linda C.B ) ( Siti Rogayah )

NIP 196611182002122003 NIP 197112151992032003
 JASA PELAYANAN FKTP PUSKESMAS JAMPANG BULAN JANUARI 2017

Jmlh hari 25 Total Dana 54802800

BULAN : Agustus 2016
Formulasi
VARIABEL Perhitungan Pajak
Persentase Total Point Jumlah
No NAMA Kehadiran Kehadiran Jenis Rangkap Tanggung Penambah Sebelum PPH 21 potongan 7% yang di terima TANDA
Masa Kerja ( G) diterima
(A) Ketenagaan Tugas Adm Jawab Prog Pengurang (A X
© ( B+C+D+E+))/ PPh 21
(B) (D) (E) (F)
XG TANGAN
1 dr,Vera Linda C.B 25 1.00 150 15.00 100.00 265.00 7,393,529 1,109,029 6,284,499 439,915 5,844,584
2 dr.Rismaini 23 0.92 150 9.00 10.00 155.48 4,337,909 216,895 4,121,013 288,471 3,832,542
3 Cucu Mariam 25 1.00 80 25.00 30.00 0.00 135.00 3,766,515 188,326 3,578,189 250,473 3,327,716
4 Noli Haryono 25 1.00 60 25.00 0.00 85.00 2,371,509 118,575 2,252,934 157,705 2,095,228
5 Ni nyoman suardi 25 1.00 80 25.00 10.00 115.00 3,208,512 160,426 3,048,087 213,366 2,834,721
6 Kurniati 25 1.00 60 24.00 0.00 84.00 2,343,609 117,180 2,226,429 155,850 2,070,579
7 Indrawati 25 1.00 80 23.00 0.00 103.00 2,873,711 143,686 2,730,026 191,102 2,538,924
8 Siti Rogayah 24 0.96 80 23.00 50.00 0.00 146.88 4,097,968 204,898 3,893,070 194,653 3,698,416
9 Arif Irsiyyadi 25 1.00 60 23.00 20.00 103.00 2,873,711 143,686 2,730,026 191,102 2,538,924
10 Runi Khaerunisa 25 1.00 80 8.00 0.00 88.00 2,455,210 122,760 2,332,449 163,271 2,169,178
11 Dewi Komala 0 - 60 5.00 10.00 0.00 - 0 0 0 0
12 Lely Mauli 24 0.96 60 10.00 15.00 81.60 2,276,649 113,832 2,162,816 151,397 2,011,419
13 Kasuhaevi 25 1.00 60 6.00 5.00 71.00 1,980,908 0 1,980,908 138,664 1,842,244
14 Ismawati Diah 25 1.00 60 4.00 10.00 74.00 2,064,608 0 2,064,608 144,523 1,920,085
15 Erna 0 - 60 5.00 0.00 0.00 - 0 0 0 0
16 Musdalifah 25 1.00 60 0.00 10.00 70.00 1,953,008 97,650 1,855,357 129,875 1,725,482
16 drg taufik 25 1.00 150 2.00 10.00 162.00 4,519,818 225,991 4,293,827 300,568 3,993,259
17 rama yanti 25 1.00 60 6.00 10.00 76.00 2,120,408 106,020 2,014,388 141,007 1,873,381
18 yanti Prihatin 25 1.00 60 10.00 0.00 70.00 1,953,008 97,650 1,855,357 129,875 1,725,482
19 Ika 25 1.00 60 0.00 0.00 60.00 1,674,006 83,700 1,590,306 111,321 1,478,985
20 Leny 25 1.00 25 0.00 0.00 25.00 697,503 41,850 655,653 45,896 609,757
21 Deden A Mukti 25 1.00 25 0.00 0.00 25.00 697,503 41,850 655,653 45,896 609,757

Jumlah 1994.96 55,659,600 3,334,007 52,325,593 3,662,792 48,662,801

Mengetahui/Menyetujui
Kepala UPF Puskesmas Jampang Bendahara JKN UPF Puskesmas Jampang

( dr.Vera Linda C.B ) ( Siti Rogayah )

NIP 196611182002122003 NIP 197112151992032003
Kode Program :16 Kode Kegiatan :0318 Kode Rekening :5.2.2.03.12

DAFTAR PENERIMAAN JASA PELAYANAN DANA KAPITASI JKN PUSKESMAS JAMPANG

SUSULAN BULAN : DESEMBER 2016

No NAMA NIP GOL NPWP JUMLAH (Rp) POT.PAJAK PPH 21 JUMLAH DITERIMA (Rp) Tanda Tangan
1 2 3 4 5 6 7 8 9
1 dr,Vera Linda C.B 19661118.200208.2.003 IV A 24.850.609.9-403.000 82,487 12,373 70,114
2 dr.Rismaini 19760111.200701.2.006 III D 36.299.269.5-403.000 46,317 2,316 44,002
3 Cucu Mariam 19700410.199002.2.002 III D 69.732.770.0-404.000 30,754 1,538 29,216
4 Noli Haryono 19640327.199012.2.001 III D 69.732.771.0.403.000 20,108 1,005 19,103
5 Ni nyoman suardi 19701209.199002.2.001 III D 69.732.769.0-403.000 37,228 1,861 35,367
6 Kurniati 19680708.199103.2.006 III C 69.732.777.4-403.000 27,517 4,127 23,389
7 Indrawati 19720813.199203.2.003 III D 35.314.553.5-434.000 35,796 1,790 34,007
8 Siti Rogayah 19711215.199203.2.003 III C 73.554.417.3-403.000 43,703 2,185 41,518
9 Arif Irsiyyadi 19730411.199203.1.001 II C 73.544.521.5-412.000 31,127 1,556 29,571
10 Runi Khaerunisa 19790603.201001.2.006 II D 58.214.772.4-411.000 23,283 1,164 22,119
11 Dewi Komala 19711215.199203.2.003 III C 34.850.441.6-403.000 0 0 0
12 Lely Mauli 19750404.200501.2.011 II D 09.208.547.1-403.001 21,291 1,065 20,227
13 Kasuhaevi 198306012011012000 III B 34.850.441.6-403.000 19,050 0 19,050
14 Ismawati Diah 198310012012112000 II D 73.072.571.0-403.000 23,657 0 23,657
15 Erna II D 0 0 0
16 Musdalifah 19910313.201001.2.001 II C 73.430.717.6-809.000 22,661 0 22,661
17 drg taufik 1000673 PTT 72.128.677.1-016.000 21,042 1,052 19,990
18 Rama yanti 5000518 PTT 73.554.417.3-403.000 21,042 1,052 19,990
19 yanti Prihatin 6 PTT 71.636.989.7-404.000 21,042 1,052 19,990
20 Ika 4000837 PTT 70.391.400.2-434.000 20,233 1,012 19,221
21 Leny Honor 11,330 680 10,651
22 Deden A Mukti Honor 11,330 680 10,651
571,000 36,509 534,491
Jumlah
Terbilang : /// Lima Ratus Tujuh Puluh Satu Ribu Rupiah ///
Mengetahui
Kepala Puskesmas Jampang Yang membayarkan
dr Vera Linda C.B Siti Rogayah
NIP. 19661118.200208.2.003 NIP. 19711215.199203.2.003
Kode Program :16 Kode Kegiatan :0318 Kode Rekening :5.2.2.03.12

DAFTAR PENERIMAAN JASA PELAYANAN DANA KAPITASI JKN PUSKESMAS JAM

BULAN : JANUARI 2017

No NAMA NIP GOL NPWP JUMLAH (Rp)

1 2 3 4 5 6
1 dr,Vera Linda C.B 19661118.200208.2.003 IV A 24.850.609.9-403.000 7,294,354
2 dr.Rismaini 19760111.200701.2.006 III D 36.299.269.5-403.000 4,279,722
3 Cucu Mariam 19700410.199002.2.002 III D 69.732.770.0-404.000 3,715,992
4 Noli Haryono 19640327.199012.2.001 III D 69.732.771.0.403.000 2,339,699
5 Ni nyoman suardi 19701209.199002.2.001 III D 69.732.769.0-403.000 3,165,474
6 Kurniati 19680708.199103.2.006 III C 69.732.777.4-403.000 2,312,173
7 Indrawati 19720813.199203.2.003 III D 35.314.553.5-434.000 2,835,164
8 Siti Rogayah 19711215.199203.2.003 III C 73.554.417.3-403.000 4,042,999
9 Arif Irsiyyadi 19730411.199203.1.001 II C 73.544.521.5-412.000 2,835,164
10 Runi Khaerunisa 19790603.201001.2.006 II D 58.214.772.4-411.000 2,422,276
11 Dewi Komala 19711215.199203.2.003 III C 34.850.441.6-403.000 0
12 Lely Mauli 19750404.200501.2.011 II D 09.208.547.1-403.001 2,246,111
13 Kasuhaevi 19730411.199203.1.001 III B 34.850.441.6-403.000 1,954,336
14 Ismawati Diah 19790603.201001.2.006 II D 73.072.571.0-403.000 2,036,914
15 Erna II D 0
16 Musdalifah 19910313.201001.2.001 II C 73.430.717.6-809.000 1,926,811
17 drg taufik 1000673 PTT 72.128.677.1-016.000 4,459,190
18 Rama yanti 5000518 PTT 73.554.417.3-403.000 2,091,966
19 yanti Prihatin 6 PTT 71.636.989.7-404.000 1,926,811
20 Ika 4000837 PTT 70.391.400.2-434.000 1,651,552
21 Leny Honor 688,147
22 Deden A Mukti Honor 688,147
54,913,000
Jumlah
Terbilang : /// Lima Puluh Empat Juta Sembilan Ratus Tiga Belas Ribu Rupiah ///
Mengetahui
Kepala Puskesmas Jampang

dr Vera Linda C.B

NIP. 19661118.200208.2.003
Rekening :5.2.2.03.12

N PUSKESMAS JAMPANG

POT.PAJAK PPH 21 JUMLAH DITERIMA (Rp) Tanda Tangan

7 8 9
1,094,153 6,200,201
213,986 4,065,735
185,800 3,530,192
116,985 2,222,714
158,274 3,007,201
115,609 2,196,564
141,758 2,693,406
202,150 3,840,849
141,758 2,693,406
121,114 2,301,162
0 0
112,306 2,133,805
0 1,954,336
0 2,036,914
0 0
0 1,926,811
222,960 4,236,231
104,598 1,987,367
96,341 1,830,470
82,578 1,568,974
41,289 646,858
41,289 646,858
3,192,945 51,720,055

Yang membayarkan

Siti Rogayah
NIP. 19711215.199203.2.003