Lembar Ke 1

FAKTUR PAJAK

Kode dan Nomor Seri Faktur Pajak: 020.902.14.00000141

Pengusaha Kena Pajak

Nama : pt.Surya Medika Utama

Alamat : Jl.Ngagel Jaya No 53, Surabaya

NPWP : 02.355.048.6-606.000

Pembeli Barang Kena Pajak/ Penerima Jasa Kena Pajak

Nama : RSUD Syamrabu

Alamat : Jl.Pemuda Kafah No.09 Bangkalan

NPWP : 00.117.413.5-644.000
No.
Urut Nama Barang Kena Pajak/ Jasa Kena Pajak

Harga Jual/Penggantian/Uang Muka/Termin *)

Dikurangi Potongan Harga

Dikurangi Uang Muka yang telah diterima

Dasar Pengenaan Pajak

PPN = 10 % x Dasar Pengenaan Pajak

Pajak Penjualan Atas Barang Mewah

Tarif DPP PPnBM

………… % Rp………………………….. Rp…………………………..

………… % Rp………………………….. Rp…………………………..

………… % Rp………………………….. Rp…………………………..

………… % Rp………………………….. Rp…………………………..

Jumlah Rp…………………………..

*) Coret yang tidak perlu

: Untuk Pembeli BKP/Penerima JKP
Sebagai Bukti Pajak Masukan

Harga Jual/Penggantian/Uang
Muka/Termin
(Rp.)
6,430,000

6,430,000

6,430,000

643,000

Surabaya, 28 Desember 2012

Nama Moh.Ashar Rofaudin

DIREKTUR
 020.000.14.23936044

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

RSUD Kodya Dati II Pasuruan

Jl.DR.Wahidin Selatan 1 - 4 Purutrejo,Purworejo Pasuruan

00.155.061.5-624.000

1 Perincian terlampir 2,250,000

2,250,000
-
-
2,250,000
225,000

Surabaya, 28 Pebruari 2014

Moh.Ashar Rofaudin
 020.000.15.79546405

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

RSUD dr.M.Soewandhie

Jl.Tambak Rejo 45 - 47 Surabaya

00.252.480.9-616.000

1 Perincian terlampir 53,580,600

53,580,600
-
-
53,580,600
5,358,060

Surabaya, 11 Maret 2015

Moh.Ashar Rofaudin
 020.003.14.84845883

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya
02.355.048.6-606.000

RSUD Pare

02.286.123.5-622.000

Dipindahkan 10,095,000.00
38 Cancell Screw 6.5(full)-70mm 1 Rp 195,000 195,000.00

10,290,000.00
-
-
10,290,000.00
1,029,000.00

Surabaya, 09 Desember 2014

Moh.Ashar Rofaudin
DIREKTUR
 010.001.15.19801845

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

PT. PALAGIMATA MEDIKA ALTA

BTN TABARIA C2 NO. 1 MAKASSAR
71.520.575.3-804.000

1 Perincian terlampir 4,500,000

4,500,000
-
-
4,500,000
450,000

Surabaya, 27 Maret 2015

Moh.Ashar Rofaudin
 020.000.15.79546284

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

Pemegang Kas RSD Kab Madiun

Jl.A.Yani KM 5 Caruban
00.192.878.7-621.000

1 Perincian terlampir 41,926,000

41,926,000
-
-
41,926,000
4,192,600

Surabaya, 08 Januari 2015

Moh.Ashar Rofaudin
 020.003.14.08791227

PT.SURYA MEDIKA UTAMA

JL.NGAGEL JAYA NO.53 , SURABAYA

02.355.048.6-606.000

PT.SURABAYA ORTHOPEDI AND TRAUMATOLOGY HOSPITAL

Jl.Emerald Mansion TX.10 Citraland Surabaya

21.107.327.5-604.000

1 Perincian terlampir 800,000

800,000
-
-
800,000
80,000

Surabaya, 13 Oktober 2014

Moh.Ashar Rofaudin
DIREKTUR
 020.001.15.19801941

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

RSU.DR.WAHIDIN SUDIRO HUSODO

JL.GAJAH MADA NO.100 MOJOKERTO
00.033.829.3-602.000

1 Perincian terlampir 57,525,400

57,525,400
-
-
57,525,400
5,752,540

Surabaya, 07 Mei 2015

Moh.Ashar Rofaudin
DIREKTUR
 020.000.13.00000016

PT.Risa Implantama

Jl.Ploso Timur IV/64, Surabaya

01.621.081.7-619.000

Bendahara Pengeluaran RSUD Pamekasan

Jl.Panglegur Pamekasan
00.454.665.1.608.000

1 Perincian terlampir

Surabaya, 15 Pebruari 2013

Diana Arijani
DIREKTUR
 43,991,155

43,991,155
-
-
43,991,155
4,399,115

ri 2013
 010.001.14.09492075

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

RSUD.Syamrabu
Jl.Pemuda Kafah No . 09 Bangkalan
00.117.413.5-644.000

1 Perincian terlampir 4,006,900

4,006,900
-
-
4,006,900
400,690

Surabaya, 28 Maret 2014

Moh.Ashar Rofaudin
DIREKTUR
 010.001.14.09492074

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

CV.Bisturi
Jl.Patimura No.03 Kav.03 RT.003/RW.002 Kel.Klojen Kec.Klojen Malang
31.318.782.5-623.000

1 Perincian terlampir 2,997,950

2,997,950
-
-
2,997,950
299,795

Surabaya, 28 Maret 2014

Moh.Ashar Rofaudin
 020.003.14.08793078

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

RSUD.RA BASOENI
Jl.Raya Gedeg 17 , Mojokerto
20.018.829.0-602.000

1 Perincian terlampir 89,982,700

89,982,700
-
-
89,982,700
8,998,270

Surabaya, 10 November 2014

Moh.Ashar Rofaudin
 010.003.14.84845878

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya

02.355.048.6-606.000

RS.WILLIAM BOOTH
JL.DIPONEGORO SURABAYA
01.216.244.2-609.001

1 Perincian terlampir 4,732,200

4,732,200
-
-
4,732,200
473,220

Surabaya, 02 Desember 2014

Moh.Ashar Rofaudin
 020.001.14.08791267

PT.SURYA MEDIKA UTAMA

JL.NGAGEL JAYA NO.53

02.355.048.6-606.000

RSUD RAA SOEWONDO PATI

JL.Dr.SOESANTO NO.114 PATI

00.004.015.4 - 507.000

1 Perincian terlampir 36,830,610

36,830,610
-
-
36,830,610
3,683,061

Surabaya, 11 November 2014

Moh.Ashar Rofaudin
 020.003.14.84845899

PT.SURYA MEDIKA UTAMA

JL.NGAGEL JAYA NO.53

02.355.048.6-606.000

Bendahara Pengeluaran RSUD Dr.Soetomo Surabaya

Jl.Mayjen.Prof.DR.Moestopo 6-8 Surabaya

00.281.411.9-606.000

1 Perincian terlampir 56,977,465

56,977,465
-
-
56,977,465
5,697,747

Surabaya, 24 Desember 2014

Moh.Ashar Rofaudin
 020.002.15.42469216

PT.SURYA MEDIKA UTAMA

JL.NGAGEL JAYA NO.53

02.355.048.6-606.000

RSUP.H.ADAM MALIK
JL.BUNGLAU NO.17 , MEDAN
00.428.656.3-121.000

1 Perincian terlampir 1,845,000

1,845,000
-
-
1,845,000
184,500

Surabaya, 27 Juli 2015

Moh.Ashar Rofaudin
 020.003.14.08791278

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya
02.355.048.6-606.000

RSU Kudus
Jl.Lukmonohadi 19 Kudus
00.003.869.5-506.008

Pindahan 49,578,346
1 T.Elastic Nail 40 1 Rp 6,270,000 6,270,000
2 Interlocking nail tibia 10x39 1 Rp 10,345,500 10,345,500
3 Interlocking nail tibia 10x34 1 Rp 10,345,500 10,345,500
4 Bipolar 47 1 Rp 9,025,000 9,025,000
.

85,564,346.00

85,564,346.00
8,556,434.60
Surabaya, 03 November 2014

Moh.Ashar Rofaudin
DIREKTUR
 020.000.15.79546302

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya
02.355.048.6-606.000

Bendahara Rutin Swadana RSU Dr.Kanujoso Djatiwibowo

Jl.MT.Haryono no.656 - Balikpapan
00.057.232.1-721.000

1 Broad plate ACP hole 10 5 Rp 809,100 4,045,500

2 Broad plate ACP hole 11 2 Rp 864,000 1,728,000
3 Broad plate ACP hole 12 3 Rp 864,000 2,592,000
4 Reconstruction straight plate B 3.5MM hole 8 2 Rp 523,800 1,047,600
5 Reconstruction straight plate B 3.5MM hole 9 2 Rp 523,800 1,047,600
6 Reconstruction straight plate B 3.5MM hole 10 2 Rp 523,800 1,047,600
7 Small bone type A hole 8 3 Rp 468,000 1,404,000
8 Small bone type A hole 9 2 Rp 468,000 936,000
9 T.Plate hole 5 2 Rp 688,500 1,377,000
10 T.Plate hole 6 4 Rp 688,500 2,754,000
11 T.Plate hole 7 2 Rp 688,500 1,377,000
2 Rp 733,500 1,467,000

20,823,300
-
-
20,823,300
2,082,330

Surabaya, 23 Januari 2015

Moh.Ashar Rofaudin
DIREKTUR
 010.001.15.19801997

PT.Surya Medika Utama

Jl.Ngagel Jaya No 53, Surabaya
02.355.048.6-606.000

PT.ALPEN AGUNGRAYA

JL.SATELIT INDAH 2 DARMO SATELIT TANJUNGSARI SUKOMANUNGGAL SURABAYA

01.756.409.7-631.000

1 Small bone B hole 6 1 Rp 2,160,000 2,160,000

2 Cortex screw 3.5-14mm 1 Rp 160,000 160,000
3 Cortex screw 3.5-18mm 1 Rp 160,000 160,000
4 Cortex screw 3.5-20mm 5 Rp 160,000 800,000
5 S. Wire 0.8 1 Rp 220,000 220,000

3,500,000
-
-
3,500,000
350,000

Surabaya, 12 Juni 2015

Moh.Ashar Rofaudin
DIREKTUR