Nomor : B / / 092021 BANYUWANGI, 20-09-2021

Lampiran: 1

Kepada Yth.
Bapak/Ibu
MAHASISWA PRAKTEK ST
DI
JLN LETKOL ISTIQLAH

Perihal : Penetapan Iuran Pertama Kepesertaan Bukan Penerima Upah

Berdasarkan pendaftaran yang dilakukan oleh Wadah untuk menjadi peserta Bukan Penerima Upah (BPU) di
BPJS Ketenagakerjaan, bersama ini kami tetapkan besaran iuran yang harus dibayaran dengan penjelasan
sebagai berikut :

Program Jumlah TK Dasar Upah Jumlah Iuran

(Rp) (Rp)
JHT 0 0.00 0.00
JKM 73 73,000,000.00 1,489,200.00
JKK 73 73,000,000.00 2,190,000.00
Jumlah iuran yang harus dibayar 3,679,200.00

Pembayaran di atas dapat dilakukan melalui kanal pembayaran antara lain ATM dan Teller Bank kerjasama
(Mandiri, BRI, BTN, BCA, BJB, BNI), Indomaret, Alfamart, Tokopedia, PPOB atau metode pembayaran
lainya dengan menggunakan kode tagihan dibawah ini :

Nomor Kode Tagihan : 0626191000072187

1
Perlindungan sosial ketenagakerjaan diberikan kepada peserta sejak iuran pertama tersebut dibayarkan.

Demikian kami sampaikan, atas perhatianya kami ucapkan terima kasih.

ANDRI YUSTIAN NUGRAHA

KEPALA BIDANG PEMASARAN BPU
 RINCIAN IURAN TENAGA KERJA BUKAN PENERIMA UPAH
BPJS KETENAGAKERJAAN

NO NIK NAMA BLTH BLN Penghasilan Dasar Upah JHT JKK JKM Iuran JHT Iuran JKK Iuran JKM Total Iuran Kode Iuran

1 3510035003990006 SINTA ERFAYANTI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

2 3510186603000002 ANA LUTFIAH HASANAH 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

3 3510076009980005 INA WIJAYANTI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

4 7504036904980001 APRIANA AHMAD 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

5 3510135703990002 ALMIRA REBINA PRISTA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

6 3510204207980007 RAGIL KUSUMA PUTRI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

7 6402134509990004 LINDA SEPTI ANGGRAENI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

8 3510225904980003 INTAN NOVIA INDRIA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239
DARNA
9 3510215505980002 SITI NURKHOLISA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

10 3510215706990002 NUR DINA KAMELIA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

11 3510184208970003 SITI MARIYANTI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

12 1406084406990001 MALA EFRIANI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

13 9111021804990002 ANGGI WAHYU 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

SUDARSONO
14 3510075312990003 DEFI WULANDARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

15 3510135403000001 ALINGKAH DWI RIZKI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

16 3509064308980004 MUHAMMAD NURUL 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

HIDAYAT
17 3510215303990003 LAILY DAMAYANTI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

18 3510035703990001 PISCALITA DAMAYANTI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

AINUN SHOLEHA
19 3510067105990001 LUTVY ERAWATI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

KNR50501
 RINCIAN IURAN TENAGA KERJA BUKAN PENERIMA UPAH
BPJS KETENAGAKERJAAN

NO NIK NAMA BLTH BLN Penghasilan Dasar Upah JHT JKK JKM Iuran JHT Iuran JKK Iuran JKM Total Iuran Kode Iuran

20 3510164606980004 FATIMA HARIFATUN ANISA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

21 3510020209990003 ADITYA RUSWANDI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

22 3510136405990003 SITI NUR HASANAH 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

23 3510182703980001 DICKY ZULKILFY AL 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

FATTAH
24 3510166404990003 ANGRAINI WULANDARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

25 3512100706990002 GILANG AKBAR SEJATI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

26 3512095205990002 RINI ANDRIAN EGA SUCI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

27 3510135304990002 APRILIANI BISROHUL 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

KAMILA
28 3510150111980001 NOVITASARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

29 3510225009980001 FELLYA INDAH KURNIA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239
SARI
30 3510165703990003 SITI RATNASARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

31 3510187003000004 VITTA JUANA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

32 3510155703990002 NILA NI'MATUL MUKMINAH 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

33 3510096502980003 EFI NOVITA SARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

34 3510016204000002 RAFICA EKA AFRENTIA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

35 3510145904980002 YUSTIKA KUSUMAWATI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

36 3510042905980001 HASBIN FIRDIAN UTAMA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

37 3510134903990007 RIKE NUR SAFITRI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

38 3510131205950002 AHMAD TAUFIK 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

KNR50501
 RINCIAN IURAN TENAGA KERJA BUKAN PENERIMA UPAH
BPJS KETENAGAKERJAAN

NO NIK NAMA BLTH BLN Penghasilan Dasar Upah JHT JKK JKM Iuran JHT Iuran JKK Iuran JKM Total Iuran Kode Iuran

39 3510087107990005 RISKI NURAINI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

40 3510132808990003 MOHAMMAD YOGI BAYU 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239
PRATAMA
41 3510217012990004 AMELIYA SUSANTI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

42 3510015606990004 HANY RYZCA WULANDARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

43 3510235205990003 RENA INDAR KHOFIFAH 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

44 3510174206980001 NABILA DIAN PRATIWI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

45 3511165309990001 EKA RIZKI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

WAHYUNINGTIYAS
46 5101044707980002 NI LUH GEDE YULIA SAPTA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239
ANGGRENI
47 3510127108990001 ANIS MAISAROH 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

48 3510224204990002 DESY AYU APRILIA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

49 5101015504950008 RIZKI UMAIYA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

50 3510090504990002 SARWONO DWI SAPUTRO 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

51 5101015408980004 NI PT. ERNA PUSPAYANI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

52 3510166110980004 OCTAVIA ANGGRAINI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

53 3371027112980006 ANNISA AYU NAMITA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

54 3510052402990001 SHELVAN DANDY MISKATU 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239
RANGGA
55 5101026503990002 KADEK TRISNA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239
DAMAYANTI
56 7504065104990001 NUR'AIN HADJARATI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

57 3510134503000009 NUR VIKA INDAH SARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

KNR50501
 RINCIAN IURAN TENAGA KERJA BUKAN PENERIMA UPAH
BPJS KETENAGAKERJAAN

NO NIK NAMA BLTH BLN Penghasilan Dasar Upah JHT JKK JKM Iuran JHT Iuran JKK Iuran JKM Total Iuran Kode Iuran

58 3510166203000008 ALVIANA NINGTYAS 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

59 3510185003990010 SILVIA LAILATUS SAFITRI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

60 3510165607980004 CHUSNUL CHOTIMAH 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

61 5108044406970004 LUH AYU WISNAWATI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

62 5101041208980001 ALDEO ARMAN 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

63 3510080308990003 DAVID SUPRAYITNO 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

PUTRA
64 3510160909980002 IKHLAS BEKTI DERMAWAN 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

65 3510211405990003 FERDIANSYAH DWI PUTRA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

66 5101015407990003 NAILLA HIMA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

67 3510220510980002 OKTAVIAN TRI ANGGARA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

68 3510096403970002 WULANDARI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

69 3510135703990004 ALFI NURDINA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

70 3510136202990002 IDA AYU RATNA PUTRI 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

71 3510086008990002 ULYVIA DITA AYU AGUSTIN 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

72 5108021507990001 ZAHARA SYIFA ANNISA 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

73 3510132204990005 TRI WARIS SUBARIYONO 09-2021 3 1,000,000 0 1 1 0 30,000 20,400 50,400 921091829239

TOTAL 73,000,000 0 73 73 0 2,190,000 1,489,200 3,679,200

KNR50501