SELF ASSESSMENT
TINGKAT KOMPONEN DALAM NEGERI
N I L A I (Rp)
TKDN Harga Satuan
No. Uraian Jumlah Satuan
(%) ( Rp) KDN KLN TOTAL
(1) (4) (5) (6) (7) (8)
A Insecticida
B Rodentisida
C Others
- - -
- - -
- - -
Integrated Pest Management System with Good Services & Good Quality
PT. Ridha Pratama Indo
Head Office :
GRAHA 73, Jl. HM. Tohir No. 73A Rt. 001 Rw. 003.
Pondok Cina. Beji. Depok 16424
Telp : +62217867936, Fax : +62217867936
Email : info@javapest.co.id
FORMULIR ISIAN PENILAIAN SENDIRI CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK
PERALATAN TERPASANG
Penyedia Barang / Jasa :
Alamat :
Nama Jasa :
Pengguna Barang/Jasa :
No. Pelelangan :
:
BIAYA ( Rp)
TKDN Satuan/ Harga Satuan
No. Uraian Jumlah
(%) Durasi ( Rp) KDN KLN TOTAL
(1) (2) (5) (6) (7) (8) (9)
1 Trap Monitoring Rodent 100% 220 kali 2,250.00 495,000.00 - 495,000.00
Trap Mass Rodent
2 100% 55 kali 2,917.00 160,435.00 - 160,435.00
Box Baiting Rodent
3 100% 220 kali 2,917.00 641,740.00 - 641,740.00
Black Box Rodent
4 100% 220 kali 2,917.00 641,740.00 - 641,740.00
- - -
- - -
SUB TOTAL 1,938,915.00 - 1,938,915.00
Integrated Pest Management System with Good Services & Good Quality
PT. Ridha Pratama Indo
Head Office :
GRAHA 73, Jl. HM. Tohir No. 73A Rt. 001 Rw. 003.
Pondok Cina. Beji. Depok 16424
Telp : +62217867936, Fax : +62217867936
Email : info@javapest.co.id
FORMULIR ISIAN PENILAIAN SENDIRI CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK PERSONIL / KONSULTAN
Penyedia Barang / Jasa : PT. RIDHA PRATAMA INDO
Alamat : Jl. H.M. Tohir No. 73A RT. 001/003. Depok
Nama Jasa : Pekerjaan Jasa Pembersihan, Pengendalian Hama, dan Fumigasi
Pengguna Barang/Jasa : RSUD KiSA Kota Depok
No. Pelelangan : -
BIAYA (RP)
Kewargan TKDN Satuan/ Harga Satuan
No. Uraian Pekerjaan Kualifikasi Jumlah
egaraan (%) Durasi (Rp) KDN KLN TOTAL
(1) (2) (3) (4) (5) (6) (7) (8) (9)
1 Team Leader(SPV) WNI 100% 11 bulan 360,000 3,960,000 - 3,960,000
2 Teknisi 2 orang WNI 100% 11 bulan 8,624,840 94,873,240 - 94,873,240
- - -
- - -
- - -
- - -
- - -
SUB TOTAL ### - ###
Integrated Pest Management System with Good Services & Good Quality
PT. Ridha Pratama Indo
Head Office :
GRAHA 73, Jl. HM. Tohir No. 73A Rt. 001 Rw. 003.
Pondok Cina. Beji. Depok 16424
Telp : +62217867936, Fax : +62217867936
Email : info@javapest.co.id
FORMULIR ISIAN PENILAIAN SENDIRI CAPAIAN KOMPONEN DALAM NEGERI UNTUK ALAT
KERJA / FASILITAS KERJA
Penyedia Barang / Jasa :
Alamat :
Nama Jasa :
Pengguna Barang/Jasa :
No. Pelelangan :
N I L A I (Rp)
Satuan/ Biaya Depresiasi /
No. Uraian Jumlah
Durasi Sewa Alat (Rp) KDN KLN TOTAL
(1) (2) (5) (6) (7) (8)
1 Tools 11 bulan 16,667.00 183,337.00 - 183,337.00
2 Unifrom + APD 11 bulan 200,000.00 2,200,000.00 - 2,200,000.00
3 Hand Sprayer 11 bulan 222,222.00 - 2,444,442.00 2,444,442.00
4 ULV Fog 11 bulan 187,500.00 - 2,062,500.00 2,062,500.00
5 Thermal Fog 11 bulan 833,333.00 - 9,166,663.00 9,166,663.00
6 Sarung tangan 11 bulan 8,333.00 91,663.00 - 91,663.00
7 Gelas Ukur 11 bulan 11,667.00 128,337.00 - 128,337.00
8 Corong 11 bulan 5,000.00 55,000.00 - 55,000.00
9 Raket Nyamuk (area dalam) 11 bulan 16,667.00 - 183,337.00 183,337.00
10 Trays Bait Rodent 1,100 pcs 1,500.00 1,650,000.00 - 1,650,000.00
- - -
- - -
SUB TOTAL 4,308,337.00 13,856,942.00 18,165,279.00
Integrated Pest Management System with Good Services & Good Quality
PT. Ridha Pratama Indo
Head Office :
GRAHA 73, Jl. HM. Tohir No. 73A Rt. 001 Rw. 003.
Pondok Cina. Beji. Depok 16424
Telp : +62217867936, Fax : +62217867936
Email : info@javapest.co.id
Integrated Pest Management System with Good Services & Good Quality
PT. Ridha Pratama Indo
Head Office :
GRAHA 73, Jl. HM. Tohir No. 73A Rt. 001 Rw. 003.
Pondok Cina. Beji. Depok 16424
Telp : +62217867936, Fax : +62217867936
Email : info@javapest.co.id
FORMULIR ISIAN PENILAIAN SENDIRI CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK JASA UMUM
N I L A I (RP)
Negara Asal /
Spesifikasi / TKDN Harga satuan
No. Uraian Pekerjaan Kepemilikan / Jumlah Satuan
Kualifikasi (%) (Rp) KDN KLN TOTAL
Warga Negara
1 Administrasi dan Dokum Work order Javapest 22 100% kali 52,500.00 1,155,000.00 - 1,155,000.00
2 Management Fee 11 100% 1,399,171.00 15,390,881.00 - 15,390,881.00
- - -
- - -
- - -
- - -
- - -
- - -
- - -
SUB TOTAL 16,545,881 - 16,545,881
Integrated Pest Management System with Good Services & Good Quality
PT. Ridha Pratama Indo
Head Office :
GRAHA 73, Jl. HM. Tohir No. 73A Rt. 001 Rw. 003.
Pondok Cina. Beji. Depok 16424
Telp : +62217867936, Fax : +62217867936
Email : info@javapest.co.id
FORMULIR REKAPITULASI PENILAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK GABUNGAN BARANG & JASA
I. BARANG (GOODS)
Biaya Bahan (Material) Terpakai Rp 8,360,000.00 26,074,653.00 34,434,653.00 24.28% 8,360,000.00
1.
(Material Used Cost) US$
Biaya Peralatan Terpasang Rp 1,938,915.00 - 1,938,915.00 100.00% 1,938,915.00
2.
(Installed Equipment Cost) US$
Rp 10,298,915.00 26,074,653.00 36,373,568.00 28.31% 10,298,915.00
3. Sub Jumlah (Sub Total) I.
US$
II. JASA (SERVICES)
Biaya Tenaga Kerja & Konsultan Rp 98,833,240.00 - 98,833,240.00 100.00% 98,833,240.00
1.
(Personnel & Consultant Cost) US$
Biaya Alat & Fasilitas Kerja Rp 4,308,337.00 13,856,942.00 18,165,279.00 23.72% 4,308,337.00
2.
(Equipment & Work Facilities Cost) US$
Biaya Konstruksi / Fabrikasi Rp - - - 0.00% -
3.
(Construction / Fabrication Cost) US$
Jasa Umum, dll Rp 16,545,881.00 - 16,545,881.00 100.00% 16,545,881.00
4.
(Other Services Cost) US$
Rp 119,687,458.00 13,856,942.00 133,544,400.00 89.62%
5. Sub Jumlah (Sub Total) II.
US$ 119,687,458.00
JUMLAH BIAYA BARANG + JASA Rp 129,986,373.00 39,931,595.00 169,917,968.00 76.50% 129,986,373.00
III.
(TOTAL COST GOODS + SERVICES) US$
KOMPONEN BUKAN BIAYA Rp
B.
(NON COST COMPONENT) US$
JUMLAH NILAI PENAWARAN Rp
C.
(TOTAL QUOTED PRICE) US$
Catatan:
% TKDN Gabungan = Jumlah Biaya Komponen Dalam Negeri Barang (A.I.3.b) + Jumlah Biaya Komponen Dalam Negeri Jasa (A.II.5.b)
Jumlah Biaya Total (A.III.d)
Integrated Pest Management System with Good Services & Good Quality