PETUNJUK PENGGUNAAN

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kpppratamamadiun feat. kp2kpcaruban
 PETUNJUK PENGGUNAAN
Isi data pegawai dan penghasilan di sheet "Data Pegawai"
Untuk mencetak form 1721-A2, pilih nomor urut di sheet "1721-A2"
Untuk mencetak form 1721-A2, memakai kertas ukuran Folio F4 (8,5" x 13")
Untuk Impor bp_A2 Masa pajak Desember, drag ke bawah cell sesuai jumlah pegawai. NPWP Pemotong pada kolom terakhir s
kpppratamamadiun feat. kp2kpcaruban
kp
 Data Pegawai

DAFTAR PEGAWAI :

NAMA INSTANSI UPT PUSKESMAS WONOGIRI II

NAMA BENDAHARA (INSTANSI) RUTIN PUSKESMAS WOONOGIRI II

NPWP BENDAHARA (INSTANSI) 00.153.667.1-532.000

ALAMAT JL. SALAK II, SANGGRAHAN - WONOGIRI

NAMA BENDAHARA (ORANG PRIBADI) SRI MARLINA

NPWP BENDAHARA (ORANG PRIBADI) 45.245.555.3-532.000

NIP BENDAHARA 197508042007012000

TAHUN PAJAK 2017

PENGHASILAN SATU TAHUN (TERMASUK GAJI KE-13 DAN Ke- 14) PENGURANGAN
Masa JUMLAH
STATUS JUMLAH JUMLAH JUMLAH PENGHASIL
Jenis Perolehan Penghasila PENGHASILAN PPH PSL 21
NO NPWP NIP NAMA Alamat Pegawai Golongan Pangkat NIK (KAWIN/TD TANGGUNGA JABATAN JUMLAH GAJI Tunj. Tunj. n lain yg PENGURAN PENGHASILA PTKP AN KENA
Kelamin K KAWIN) N (ANAK)
Penghasilan Tunj. Istri/ BRUTO 1 BIAYA IURAN G N NETTO PAJAK
TERUTANG
(bulan) Gaji Pokok Tunj. Anak DAN TUNJ. Perbaikan Struktural/Fung Tunj. Beras Tunj. Khusus Tunj. Lain teratur TAHUN
Suami terpisah dr JABATAN PENSIUN
KELUARGA penghasilan sional
gaji

1 59.723.598.5-532.000 19650404 199803 2 003 dr. Antik Istiqomah Kedungringin RT01 RW 12, Giripurwo - IV A Pembina P 3312124404650005 TK 0 Ka.Puskesmas 0112 57,093,400 - - 57,093,400 6,480,000 869,040 - 64,442,440 3,222,122 2,711,936 5,934,058 58,508,382 54,000,000 4,508,382 225,400
2 59.723.592.8-532.000 19740721 199303 2 003 Dwi Muryani, SKM,MM Wonogiri
Tlogorejo RT 1 RW 1, Pare , Selogiri III C Penata P 3312116107740001 K 2 Ka.Sub.Bag TU 0112 49,393,400 4,939,340 1,975,736 56,308,476 5,880,000 3,476,160 - 65,664,636 3,283,231 2,674,652 5,957,883 59,706,753 67,500,000 - -
3 49.240.225.0-532.000 19591112 198902 2 001 dr.Tuty Darsari,MM Bogem Rt 03/ VII, Taman Martani, Kalasan, IV C Pembina Utama Muda P 3404105211540002 K 1 Dokter Madya 0112 68,072,200 6,807,220 1,361,444 76,240,864 14,400,000 2,607,120 - 93,247,984 4,662,399 3,621,441 8,283,840 84,964,144 63,000,000 21,964,144 1,098,200
4 59.723.584.5-532.000 19630828 198911 2 003 dr. Hidayati Sleman
Jl. - DIY
Durian No.19, Sanggrahan – Giripurwo- IV C Pembina Utama Muda P 3312126808630004 K 2 Dokter Madya 0112 68,072,200 6,807,220 2,722,888 77,602,308 14,400,000 3,476,160 - 95,478,468 4,773,923 3,686,109 8,460,032 87,018,436 67,500,000 19,518,436 975,900
5 49.151.868.4-532.000 19670307 200112 1 001 drg.S Riyanta Wonogiri
Perum BIB B4, Krisak Wetan , Singodutan - IV B Pembina Tk.I L 3312030703670005 K 2 Dokter Gigi Madya 0112 55,930,000 5,593,000 2,237,200 63,760,200 14,400,000 3,476,160 - 81,636,360 4,081,818 3,028,609 7,110,427 74,525,933 67,500,000 7,025,933 351,250
6 48.145.492.4-532.000 19780317 200604 2 003 drg. Sri Marmiyati Selogiri
Tanjung RT 5 RW IX, Bakalan , Polokarto - IV A Pembina P 3311045703780003 K 2 Dokter Gigi Madya 0112 47,399,800 4,739,980 1,895,992 54,035,772 14,400,000 3,476,160 - 71,911,932 3,595,596 2,566,699 6,162,295 65,749,637 67,500,000 - -
7 35.220.929.0-532.000 19801113 200904 2 002 dr. Estrini Wuryan Utami Sukoharjo
Jl.Empu Triguna No 6 RT5/V, Songgolangit - III D Penata Tk. I P 3314105311800001 K 0 Dokter Muda 0112 45,476,200 4,547,620 - 50,023,820 9,000,000 869,040 - 59,892,860 2,994,643 2,376,131 5,370,774 54,522,086 58,500,000 - -
8 59.723.599.3-532.000 19650116 198511 1 001 Suprayitno Sukoharjo
Perum Griya Cipta Laras RT 02 RW IX , III D Penata Tk. I L 3312121601650002 K 2 Perawat penyelia 0112 58,280,600 5,828,060 2,331,224 66,439,884 6,000,000 3,476,160 - 75,916,044 3,795,802 3,155,894 6,951,696 68,964,348 67,500,000 1,464,348 73,200
9 25.331.278.9-532.000 19621212 198503 2 016 Rini setianti,S Kep. Ns Bulusulur
Per Paramedia No 17 RT 03 RW 4 , IV A Pembina P 3312125212620003 K 0 Perawat Madya 0112 60,746,000 6,074,600 - 66,820,600 - 10,200,000 869,040 - 77,889,640 3,894,482 3,173,978 7,068,460 70,821,180 58,500,000 12,321,180 616,050
10 59.723.588.6-532.000 19621111 199003 1 010 Agus Sartono,AMKL Bulusulur - Wonogiri
Wonokarto RT 01 RW 6, Wonokarto - III D Penata Tk. I L 3312121111620002 K 1 Sanitarian Penyelia 0112 56,501,200 5,650,120 1,130,024 63,281,344 - 6,000,000 2,607,120 - 71,888,464 3,594,423 3,005,863 6,600,286 65,288,178 63,000,000 2,288,178 114,400
11 59.723.606.6-532.000 19680108 198803 2 003 Trisni Jumiarsih,AMKL Wonogiri
Pokoh RT 01 RW I, Wonoboyo, Wonogiri III D Penata Tk. I P 3312114801680001 TK 1 Sanitarian Penyelia 0112 56,501,200 - 1,130,024 57,631,224 - 6,000,000 1,738,000 - 65,369,224 3,268,461 2,737,483 6,005,944 59,363,280 58,500,000 863,280 43,150
12 59.723.607.4-532.000 19680115 198911 2 001 Sriyatmi,Am Keb Wonokarto 3/7, Wonokarto III D Penata Tk. I P 3312125501680002 K 1 Bidan Penyelia 0112 54,776,400 5,477,640 1,095,528 61,349,568 - 6,000,000 2,607,120 - 69,956,688 3,497,834 2,914,104 6,411,938 63,544,750 63,000,000 544,750 27,200
13 57.735.723.9-532.000 19780510 200604 2 011 Endang Puji A.,SKM,MM Per.Bukit Citra Jaya II RT 01 RW 3, Pencil - III D Penata Tk. I P 3312125005780001 K 0 Penylh.Kesh.Masy.Muda 0112 45,476,200 4,547,620 - 50,023,820 - 7,200,000 869,040 - 58,092,860 2,904,643 2,376,131 5,280,774 52,812,086 58,500,000 - -
14 87.556.663.0-526.000 19761021 200604 1 010 Supartono,SKM,MPH Wuryorejo
Jl.Tanjung No.50 RT 2 RW 3, III D Penata Tk. I L 3372012110760007 K 1 Penylh.Kesh.Masy.Muda 0112 45,476,200 4,547,620 909,524 50,933,344 - 7,200,000 2,607,120 - 60,740,464 3,037,023 2,419,333 5,456,356 55,284,108 63,000,000 - -
15 25.331.232.6-532.000 19750927 200501 2 008 CJ Br. Ginting, S Kep. Ns Krgasem,Laweyan
Wonokarto RT 03 RW 8, Wonokarto - III D Penata Tk. I P 3312126709750001 K 2 Perawat Muda 0112 45,476,200 4,547,620 1,819,048 51,842,868 - 7,200,000 3,476,160 - 62,519,028 3,125,951 2,462,536 5,588,487 56,930,541 67,500,000 - -
16 49.240.081.7-532.000 19791205 200312 1 002 Bagus Nurrakhmad,S Kep.Ns Wonogiri
Donoharjo RT 01 RW !, Wuryorejo - III D Penata Tk. I L 3312120512790003 K 2 Perawat Muda 0112 46,908,400 4,690,840 1,876,336 53,475,576 - 7,200,000 3,476,160 - 64,151,736 3,207,586 2,540,089 5,747,675 58,404,061 67,500,000 - -
17 45.421.230.9-532.000 19761114 199603 2 001 Novi Siswanti Wonogiri
Joho Lor RT 2 RW XI, Giriwono Wonogiri III C Penata P 3312125411760001 K 0 Ass.Apoteker Penyelia 0112 47,884,200 4,788,420 - 52,672,620 - 6,000,000 869,040 - 59,541,660 2,977,083 2,501,949 5,479,032 54,062,628 58,500,000 - -
18 59.723.585.2-532.000 19600113 198612 2001 Arenawati Wonokarto RT 02 RW 4, Wonokarto - III B Penata Muda Tk. I P 3312125301600001 K 1 Pelaksana 0112 - - - - - - - - - - 63,000,000 - -
19 59.723.597.7-532.000 19650319 198612 2 001 Retnoningsih Wonogiri
Joho Lor RT 01 RW V, Giriwono - Wonogiri III B Penata Muda Tk. I P 3312125903650004 TK 0 Pelaksana 0112 53,646,600 - - 53,646,600 - 2,220,000 869,040 - 56,735,640 2,836,782 2,548,213 5,384,995 51,350,645 54,000,000 - -
20 02.617.874.6-532.000 19821006 200604 1 009 Sri Widodo, S.Kep Manggis RT01 RW 2, Ngadirojo Kidul , III B Penata Muda Tk. I L 3312130610820001 K 2 Perawat Pertama 0112 40,581,800 4,058,180 1,623,272 46,263,252 - 3,600,000 3,476,160 - 53,339,412 2,666,970 2,197,504 4,864,474 48,474,938 67,500,000 - -
21 45.421.230.9-532.000 19810428 200604 1 010 Basuki,S Kep Ngadirojo-
Setro RT 02Wonogiri
RW 4, Wonoharjo - Wonogiri III B Penata Muda Tk. I L 3312122804810003 K 2 Perawat Pertama 0112 40,581,800 4,058,180 1,623,272 46,263,252 - 3,600,000 3,476,160 - 53,339,412 2,666,970 2,197,504 4,864,474 48,474,938 67,500,000 - -
22 45.245.528.0-532.000 19820727 200801 2 008 Yuliana DF, Amd Keb Gemutren RT 2 RW V, Pule – Selogiri, III A Penata Muda P 3312116707820003 K 1 Bidan Pelaksana Lanjutan 0112 40,161,800 4,016,180 803,236 44,981,216 - 3,180,000 2,607,120 - 50,768,336 2,538,416 2,136,607 4,675,023 46,093,313 63,000,000 - -
23 24.627.815.4-528.000 19740604 200903 1 002 Joko Subandono ,Am d. Ft Wonogiri
Per.Gedongan Indah Blok E/3 RT7 RW 9, III A Penata Muda L 3313120406740002 K 2 Fisioterapis Pelks Lanjutan 0112 37,746,800 3,774,680 1,509,872 43,031,352 - 3,180,000 3,476,160 - 49,687,512 2,484,375 2,043,989 4,528,364 45,159,148 67,500,000 - -
24 89.229.273.1-525.000 19860625 200903 2 009 Dian Kurniawati, SST ColomaduI- No.8,
Jl.Arjuna KRA Wonokarto RT03 RW II , III A Penata Muda P 3310156506860001 K 2 Bidan Pertama 0112 37,746,800 3,774,680 1,509,872 43,031,352 - 3,600,000 3,476,160 - 50,107,512 2,505,375 2,043,989 4,549,364 45,558,148 67,500,000 - -
25 58.066.996.8-532.999 19840815 201001 2 026 Hani Setyaningsih,Amd Keb Wonogiri
Perum Megatama Blok B/6 Pokoh Kidul, III A Penata Muda P 3312195508840003 K 2 Bidan Pelaksana Lanjutan 0112 36,593,200 3,659,320 1,463,728 41,716,248 - 3,180,000 3,476,160 - 48,372,408 2,418,620 1,981,521 4,400,141 43,972,267 67,500,000 - -
26 65.695.660.2-532.000 19870531 201001 2 010 Tunjung Suhasti,AMKG Wonogiri
Perum Cipta Laras RT 02 RW 9, Bulusulur - III A Penata Muda P 3310237105870001 K 2 Perawat Gigi Pelks Lanjutan 0112 36,593,200 3,659,320 1,463,728 41,716,248 - 3,180,000 3,476,160 - 48,372,408 2,418,620 1,981,521 4,400,141 43,972,267 67,500,000 - -
27 74.261.561.0-526.000 19821012 201001 2 029 Oktavia Santi S,AMG Wonogiri
Begalon RT 02 RW 4, Panularan – Laweyan III A Penata Muda P 3372015210820007 K 1 Nutrisionis Pelks Lanjutan 0112 36,593,200 3,659,320 731,864 40,984,384 - 3,180,000 2,607,120 - 46,771,504 2,338,575 1,946,758 4,285,333 42,486,171 63,000,000 - -
28 45.245.123.0-532.000 19810113 200501 2 012 Wahyu Eko Nurani, A.Md.Ak -Sukorejo
SurakartaRT 02 RW X ,Giritirto - Wonogiri III A Penata Muda P 3312125301810001 K 2 Pranata LabKes Pelks Lajtan 0112 40,161,800 4,016,180 1,606,472 45,784,452 - 3,180,000 3,476,160 - 52,440,612 2,622,030 2,174,761 4,796,791 47,643,821 67,500,000 - -
29 66.307.583.6-543.000 1983 0930 201101 2 009 Esti Wijayanti, Amd AK Griya Giri Jati 104,Lemah Ireng Bulusulur. II D Pengatur Tk. I P 3402037009830001 TK 0 Pranata LabKes Pelaks. 0112 36,593,200 - - 36,593,200 - 3,180,000 869,040 - 40,642,240 2,032,112 1,738,177 3,770,289 36,871,951 54,000,000 - -
30 45.245.406.9-532.000 19751106 200604 2003 Ardiningtyas,AMF Perum Pokoh Kidul Blok N3 RT 01 RW XIII II D Pengatur Tk. I P 3312124611750001 TK 0 Ass.Apt.Pelaksana 0112 43,619,800 - - 43,619,800 - 2,880,000 869,040 - 47,368,840 2,368,442 2,071,940 4,440,382 42,928,458 54,000,000 - -
31 45.245.625.4-532.000 19770505 200701 2 020 Tri Widiastuti,Amd Keb Wonogiri
Jl. Cempaka IV , Pokoh RT 3 RW 2, II D Pengatur Tk. I P 3312124505770009 TK 0 Bidan pelaksana 0112 40,996,200 - - 40,996,200 - 2,880,000 869,040 - 44,745,240 2,237,262 1,947,319 4,184,581 40,560,659 54,000,000 - -
32 45.245.555.3-532.000 19750804 200701 2 008 Sri Marlina,Amd Keb Wonoboyo - RT
Wonokarto Wonogiri
01 RW 2, Wonokarto - II D Pengatur Tk. I P 3312124408750001 K 2 Bidan pelaksana 0112 42,288,400 4,228,840 1,691,536 48,208,776 - 2,880,000 3,476,160 - 54,564,936 2,728,246 2,289,916 5,018,162 49,546,774 67,500,000 - -
33 45.245.584.3-532.000 19750306 200604 2 014 Titin Fatimah,Amd Keb Wonogiri
Jl. Yudhistira IV No.2B RT 02 RW 6 II D Pengatur Tk. I P 3312124603750001 K 2 Bidan pelaksana 0112 42,288,400 4,228,840 1,691,536 48,208,776 - 2,880,000 3,476,160 - 54,564,936 2,728,246 2,289,916 5,018,162 49,546,774 67,500,000 - -
34 45.246.143.7-532.000 19760405 200801 2 016 Lindaningsih, Amd Keb Wonokarto - Wonogiri
Tambakrejo RT02 /I, Tiyaran, Bulu- II D Pengatur Tk. I P 3311024504760001 K 0 Bidan pelaksana 0112 36,213,800 3,621,380 - 39,835,180 - 2,880,000 869,040 - 43,584,220 2,179,211 1,892,171 4,071,382 39,512,838 58,500,000 - -
35 45.245.324.4-532.000 19800216 200801 2009 Sri Lestari, Amd Keb Sukoharjo
Pokoh RT 01 RW I, Wonoboyo, Wonogiri II D Pengatur Tk. I P 3312155602800001 K 2 Bidan pelaksana 0112 37,354,800 3,735,480 1,494,192 42,584,472 - 2,880,000 2,607,120 - 48,071,592 2,403,579 2,022,762 4,426,341 43,645,251 67,500,000 - -
36 57.995.383.7.532.000 19651206 200701 2 012 Tuniyem Joho Lor rt 4/ rw 4, Giriwono, Wonogiri II C Pengatur P 33121246112650006 K 2 Pengadministrasi 0112 41,850,200 4,185,020 1,674,008 47,709,228 - 2,160,000 3,476,160 - 53,345,388 2,667,269 2,266,188 4,933,457 48,411,931 67,500,000 - -
37 45.245.368.1-532.000 19830903 201704 2 001 Ana Sulistyowati,Amd Keb Salak RT 01/03 Giripurwo Wonogiri II C Pengatur P 3312124309830003 K 2 Bidan 0412 18,431,280 1,843,128 737,251 21,011,659 - 1,620,000 3,476,160 - 26,107,819 1,305,390 998,053 2,303,443 23,804,376 67,500,000 - -
38 45.245.341.8-532.000 19851210 201704 2 001 Sinta Rusitasari,Amd Keb Kaloran RT 03 RW VII Giritirto Wonogiri II C Pengatur P 3312125012850004 K 2 Bidan 0412 17,868,960 1,786,896 714,758 20,370,614 - 1,620,000 3,476,160 - 25,466,774 1,273,338 967,604 2,240,942 23,225,832 67,500,000 - -
39 45.246.267.4-532.000 19830909 201704 2 001 Desi Septiana,Amd Keb Pengkol RT 01/01 Pokoh Kidul Wonogiri II C Pengatur P 3312124909830001 TK 0 Bidan 0412 18,431,280 - - 18,431,280 - 1,620,000 869,040 - 20,920,320 1,046,016 875,485 1,921,501 18,998,819 54,000,000 - -
40 45.246.212.0-532.000 19860713 201704 2 001 Nur hidayah AB,Amd Keb Kaloran Lor RT 03 RW 05 Giritirto Wonogiri II C Pengatur P 3311115307860001 K 1 Bidan 0412 17,868,960 1,786,896 357,379 20,013,235 - 1,620,000 2,607,120 - 24,240,355 1,212,017 950,628 2,162,645 22,077,710 63,000,000 - -
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146 - - - - - - - - - - - - - - -
147 - - - - - - - - - - - - - - -
148 - - - - - - - - - - - - - - -
149 - - - - - - - - - - - - - - -
150 - - - - - - - - - - - - - - -
151 - - - - - - - - - - - - - - -
152 - - - - - - - - - - - - - - -
153 - - - - - - - - - - - - - - -
154 - - - - - - - - - - - - - - -
155 - - - - - - - - - - - - - - -
156 - - - - - - - - - - - - - - -
157 - - - - - - - - - - - - - - -
158 - - - - - - - - - - - - - - -
159 - - - - - - - - - - - - - - -
160 - - - - - - - - - - - - - - -
161 - - - - - - - - - - - - - - -
162 - - - - - - - - - - - - - - -
163 - - - - - - - - - - - - - - -
164 - - - - - - - - - - - - - - -
165 - - - - - - - - - - - - - - -
166 - - - - - - - - - - - - - - -
167 - - - - - - - - - - - - - - -
168 - - - - - - - - - - - - - - -
169 - - - - - - - - - - - - - - -
170 - - - - - - - - - - - - - - -
171 - - - - - - - - - - - - - - -
172 - - - - - - - - - - - - - - -
173 - - - - - - - - - - - - - - -
174 - - - - - - - - - - - - - - -
175 - - - - - - - - - - - - - - -
176 - - - - - - - - - - - - - - -
177 - - - - - - - - - - - - - - -
178 - - - - - - - - - - - - - - -
179 - - - - - - - - - - - - - - -
180 - - - - - - - - - - - - - - -
181 - - - - - - - - - - - - - - -
182 - - - - - - - - - - - - - - -
183 - - - - - - - - - - - - - - -
184 - - - - - - - - - - - - - - -
185 - - - - - - - - - - - - - - -
186 - - - - - - - - - - - - - - -
187 - - - - - - - - - - - - - - -
188 - - - - - - - - - - - - - - -
189 - - - - - - - - - - - - - - -
190 - - - - - - - - - - - - - - -
191 - - - - - - - - - - - - - - -
192 - - - - - - - - - - - - - - -
193 - - - - - - - - - - - - - - -
194 - - - - - - - - - - - - - - -
195 - - - - - - - - - - - - - - -
196 - - - - - - - - - - - - - - -
197 - - - - - - - - - - - - - - -
198 - - - - - - - - - - - - - - -
199 - - - - - - - - - - - - - - -
200 - - - - - - - - - - - - - - -
201 - - - - - - - - - - - - - - -
202 - - - - - - - - - - - - - - -
203 - - - - - - - - - - - - - - -
204 - - - - - - - - - - - - - - -
205 - - - - - - - - - - - - - - -
206 - - - - - - - - - - - - - - -
207 - - - - - - - - - - - - - - -
208 - - - - - - - - - - - - - - -
209 - - - - - - - - - - - - - - -
210 - - - - - - - - - - - - - - -
211 - - - - - - - - - - - - - - -
212 - - - - - - - - - - - - - - -
213 - - - - - - - - - - - - - - -
214 - - - - - - - - - - - - - - -
215 - - - - - - - - - - - - - - -
216 - - - - - - - - - - - - - - -
217 - - - - - - - - - - - - - - -
218 - - - - - - - - - - - - - - -
219 - - - - - - - - - - - - - - -
220 - - - - - - - - - - - - - - -
221 - - - - - - - - - - - - - - -
222 - - - - - - - - - - - - - - -
223 - - - - - - - - - - - - - - -
224 - - - - - - - - - - - - - - -
225 - - - - - - - - - - - - - - -
226 - - - - - - - - - - - - - - -
227 - - - - - - - - - - - - - - -
228 - - - - - - - - - - - - - - -
229 - - - - - - - - - - - - - - -
230 - - - - - - - - - - - - - - -
231 - - - - - - - - - - - - - - -
232 - - - - - - - - - - - - - - -
233 - - - - - - - - - - - - - - -
234 - - - - - - - - - - - - - - -
235 - - - - - - - - - - - - - - -
236 - - - - - - - - - - - - - - -
237 - - - - - - - - - - - - - - -
238 - - - - - - - - - - - - - - -
239 - - - - - - - - - - - - - - -
240 - - - - - - - - - - - - - - -
241 - - - - - - - - - - - - - - -
242 - - - - - - - - - - - - - - -
243 - - - - - - - - - - - - - - -
244 - - - - - - - - - - - - - - -
245 - - - - - - - - - - - - - - -
246 - - - - - - - - - - - - - - -
247 - - - - - - - - - - - - - - -
248 - - - - - - - - - - - - - - -
249 - - - - - - - - - - - - - - -
250 - - - - - - - - - - - - - - -
251 - - - - - - - - - - - - - - -
252 - - - - - - - - - - - - - - -
253 - - - - - - - - - - - - - - -
254 - - - - - - - - - - - - - - -
255 - - - - - - - - - - - - - - -
256 - - - - - - - - - - - - - - -
257 - - - - - - - - - - - - - - -
258 - - - - - - - - - - - - - - -
259 - - - - - - - - - - - - - - -
260 - - - - - - - - - - - - - - -
261 - - - - - - - - - - - - - - -
262 - - - - - - - - - - - - - - -
263 - - - - - - - - - - - - - - -
264 - - - - - - - - - - - - - - -
265 - - - - - - - - - - - - - - -
266 - - - - - - - - - - - - - - -
267 - - - - - - - - - - - - - - -
268 - - - - - - - - - - - - - - -
269 - - - - - - - - - - - - - - -
270 - - - - - - - - - - - - - - -
271 - - - - - - - - - - - - - - -
272 - - - - - - - - - - - - - - -
273 - - - - - - - - - - - - - - -
274 - - - - - - - - - - - - - - -
275 - - - - - - - - - - - - - - -
276 - - - - - - - - - - - - - - -

Page 4
 Data Pegawai

277 - - - - - - - - - - - - - - -
278 - - - - - - - - - - - - - - -
279 - - - - - - - - - - - - - - -
280 - - - - - - - - - - - - - - -
281 - - - - - - - - - - - - - - -
282 - - - - - - - - - - - - - - -
283 - - - - - - - - - - - - - - -
284 - - - - - - - - - - - - - - -
285 - - - - - - - - - - - - - - -
286 - - - - - - - - - - - - - - -
287 - - - - - - - - - - - - - - -
288 - - - - - - - - - - - - - - -
289 - - - - - - - - - - - - - - -
290 - - - - - - - - - - - - - - -
291 - - - - - - - - - - - - - - -
292 - - - - - - - - - - - - - - -
293 - - - - - - - - - - - - - - -
294 - - - - - - - - - - - - - - -
295 - - - - - - - - - - - - - - -
296 - - - - - - - - - - - - - - -
297 - - - - - - - - - - - - - - -
298 - - - - - - - - - - - - - - -
299 - - - - - - - - - - - - - - -
300 - - - - - - - - - - - - - - -
JUMLAH 2,191,897,905 3,524,750

Page 5
 area staples

BUKTI PEMOTONGAN PAJAK PENGHASILAN

PASAL 21 BAGI PEGAWAI NEGERI SIPIL ATAU FORMULIR 1721 - A2
ANGGOTA TENTARA NASIONAL INDONESIA ATAU Lembar 1 : Untuk Penerima Penghasilan
ANGGOTA POLISI REPUBLIK INDONESIA ATAU Lembar 2 : Untuk Pemotong
PEJABAT NEGARA ATAU PENSIUNNYA MASA PEROLEHAN
KEMENTERIAN KEUANGAN RI PENGHASILAN [mm - mm]
DIREKTORAT JENDERAL PAJAK
1 . 2 - 12 - 17 - 00000041
NOMOR : H.0 H.02 -
1

NAMA INSTANSI/
BADAN LAIN : H.03
UPT PUSKESMAS WONOGIRI II NPWP BENDAHARA : H.05
NAMA
BENDAHARA : H.04
RUTIN PUSKESMAS WOONOGIRI II 00.153.667.1 - 621 - 000
A. IDENTITAS PENERIMA PENGHASILAN YANG DIPOTONG

1 NPWP : A.01
6 JENIS KELAMIN : A.07 LAKI-LAKI A.08 PEREMPUAN
: 7 NIK :
2 NIP/ A.02
A.09
NRP
3 NAMA : A.03 8 STATUS/JUMLAH TANGGUNGAN KELUARGA UNTUK PTKP
4 PANGKAT/ A.10 A.11 A.12
K/ TK / HB /
GOLONGA : A.04 A.05
N
5 ALAMAT : A.06 9 NAMA JABATAN A.13

###
B. RINCIAN PENGHASILAN DAN PENGHITUNGAN PPh PASAL 21
URAIAN JUMLAH (Rp)
KODE OBJEK PAJAK : X 21-100-01 21-100-02
PENGHASILAN BRUTO
1. GAJI POKOK/PENSIUN
2. TUNJANGAN ISTERI -
3. TUNJANGAN ANAK -
4. JUMLAH GAJI DAN TUNJANGAN KELUARGA (1 S.D. 3) -
5. TUNJANGAN PERBAIKAN PENGHASILAN -
6. TUNJANGAN STRUKTURAL/FUNGSIONAL
7. TUNJANGAN BERAS
8. TUNJANGAN KHUSUS
9. TUNJANGAN LAIN-LAIN
PENGHASILAN TETAP DAN TERATUR LAINNYA YANG PEMBAYARANNYA TERPISAH
10.
DARI PEMBAYARAN GAJI
-
11. JUMLAH PENGHASILAN BRUTO (4 S.D. 10) -
PENGURANGAN
12. BIAYA JABATAN/BIAYA PENSIUN -
13. IURAN PENSIUN ATAU IURAN THT/JHT -
14. JUMLAH PENGURANGAN ( 12 S.D. 14) -
PENGHITUNGAN PPh PASAL 21
15. JUMLAH PENGHASILAN NETTO (11 - 14) -
16. PENGHASILAN NETO MASA PAJAK SEBELUMNYA -
17. JUMLAH PENGHASILAN NETO UNTUK PENGHITUNGAN PPh PASAL 21 (SETAHUN/DISETA -
18. PENGHASILAN TIDAK KENA PAJAK (PTKP) -
19. PENGHASILAN KENA PAJAK SETAHUN/DISETAHUNKAN (17 - 18) -
20. PPh PASAL 21 ATAS PENGHASILAN KENA PAJAK SETAHUN/DISETAHUNKAN -
21. PPh PASAL 21 YANG TELAH DIPOTONG MASA PAJAK SEBELUMNYA -
22. PPh PASAL 21 TERUTANG -
23. PPh PASAL 21 YANG TELAH DIPOTONG DAN DILUNASI
23A. ATAS GAJI DAN TUNJANGAN -
 ATAS PENGHASILAN TETAP DAN TERATUR LAINNYA YANG PEMBAYARANNYA
23B.
TERPISAH DARI PEMBAYARAN GAJI
-

C. PEGAWAI TERSEBUT : C.01 DIPINDAHKAN C.02 PINDAHAN C.03 BARU C.03 PENSIUN
D. TANDA TANGAN BENDAHARA
1. NPWP : D.01 . 45.245.555.3-532.000 3. TANGGAL & TANDA TANGA STEMPEL & TANDA TANGAN

2. NAMA : D.02 SRI MARLINA C.03 1/10/2017

[dd - mm - yyyy]
3. NIP/NRP: D.02 197508042007012000
Masa PajakTahun PajaPembetula Nomor BuktMasa PerolMasa PerolNPWP NIP Nama
12 2016 0 1.2-12.16- 1 12 597235985532000 19650404 dr. Antik I
12 2016 0 1.2-12.16- 1 12 597235928532000 19740721 Dwi Murya
12 2016 0 1.2-12.16- 1 12 492402250532000 19591112 1dr.Tuty Da
12 2016 0 1.2-12.16- 1 12 597235845532000 19630828 1dr. Hidayat
12 2016 0 1.2-12.16- 1 12 491518684532000 19670307 drg.S Riyan
12 2016 0 1.2-12.16- 1 12 481454924532000 19780317 drg. Sri Ma
12 2016 0 1.2-12.16- 1 12 352209290532000 19801113 dr. Estrini
12 2016 0 1.2-12.16- 1 12 597235993532000 19650116 Suprayitno
12 2016 0 1.2-12.16- 1 12 253312789532000 19621212 Rini setiant
12 2016 0 1.2-12.16- 1 12 597235886532000 19621111 Agus Sart
12 2016 0 1.2-12.16- 1 12 597236066532000 19680108 Trisni Jum
12 2016 0 1.2-12.16- 1 12 597236074532000 19680115 Sriyatmi,A
12 2016 0 1.2-12.16- 1 12 577357239532000 19780510 Endang Pu
12 2016 0 1.2-12.16- 1 12 875566630526000 19761021 Supartono
12 2016 0 1.2-12.16- 1 12 253312326532000 19750927 CJ Br. Gint
12 2016 0 1.2-12.16- 1 12 492400817532000 19791205 Bagus Nurr
12 2016 0 1.2-12.16- 1 12 454212309532000 19761114 Novi Siswan
12 2016 0 1.2-12.16- 1 12 597235852532000 19600113 Arenawati
12 2016 0 1.2-12.16- 1 12 597235977532000 19650319 Retnonings
12 2016 0 1.2-12.16- 1 12 026178746532000 19821006 Sri Widodo
12 2016 0 1.2-12.16- 1 12 454212309532000 19810428 Basuki,S K
12 2016 0 1.2-12.16- 1 12 452455280532000 19820727 Yuliana D
12 2016 0 1.2-12.16- 1 12 246278154528000 19740604 Joko Suban
12 2016 0 1.2-12.16- 1 12 892292731525000 19860625 Dian Kurnia
12 2016 0 1.2-12.16- 1 12 580669968532999 19840815 Hani Setya
12 2016 0 1.2-12.16- 1 12 656956602532000 19870531 Tunjung Su
12 2016 0 1.2-12.16- 1 12 742615610526000 19821012 Oktavia Sa
12 2016 0 1.2-12.16- 1 12 452451230532000 19810113 Wahyu Eko
12 2016 0 1.2-12.16- 1 12 663075836543000 1983 0930 Esti Wijaya
12 2016 0 1.2-12.16- 1 12 452454069532000 19751106 Ardiningty
12 2016 0 1.2-12.16- 1 12 452456254532000 19770505 Tri Widias
12 2016 0 1.2-12.16- 1 12 452455553532000 19750804 Sri Marlin
12 2016 0 1.2-12.16- 1 12 452455843532000 19750306 Titin Fati
12 2017 0 1.2-12.16- 1 12 452461437532000 19760405 Lindanings
12 2016 0 1.2-12.16- 1 12 452453244532000 19800216 Sri Lestari
12 2016 0 1.2-12.16- 1 12 57.995.383.7.532.000 19651206 Tuniyem
12 2016 0 1.2-12.16- 1 12 452453681532000 19830903 Ana Sulist
12 2016 0 1.2-12.16- 1 12 452453418532000 19851210 Sinta Rusi
12 2016 0 1.2-12.16- 1 12 452462674532000 19830909 Desi Septi
12 2016 0 1.2-12.16- 1 12 452462120532000 19860713 Nur hidaya
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
12 2016 0 1.2-12.16- 1 12 000000000000000 0 0
Pangkat Golongan Alamat Jenis Kela NIK Status PTK Jumlah Ta Nama Jaba Kode Pajak
Pembina IV A KedungringF 331212440465TK 0 Ka.Puskes 21-100-01
Penata III C Tlogorejo RF 331211610774K 2 Ka.Sub.Bag21-100-01
Pembina U IV C Bogem Rt 0F 340410521154K 1 Dokter Ma 21-100-01
Pembina U IV C Jl. Durian F 331212680863K 2 Dokter Ma 21-100-01
Pembina TkIV B Perum BIB BM 331203070367K 2 Dokter Gig 21-100-01
Pembina IV A Tanjung RT F 331104570378K 2 Dokter Gig 21-100-01
Penata Tk. III D Jl.Empu Tr F 331410531180K 0 Dokter Mu 21-100-01
Penata Tk. III D Perum GriyaM 331212160165K 2 Perawat pe21-100-01
Pembina IV A Per ParameF 331212521262K 0 Perawat M 21-100-01
Penata Tk. III D WonokartoM 331212111162K 1 Sanitarian 21-100-01
Penata Tk. III D Pokoh RT 0F 331211480168TK 1 Sanitarian 21-100-01
Penata Tk. III D WonokartoF 331212550168K 1 Bidan Peny21-100-01
Penata Tk. III D Per.Bukit C F 331212500578K 0 Penylh.Ke 21-100-01
Penata Tk. III D Jl.Tanjung M 337201211076K 1 Penylh.Ke 21-100-01
Penata Tk. III D WonokartoF 331212670975K 2 Perawat M 21-100-01
Penata Tk. III D Donoharjo M 331212051279K 2 Perawat M 21-100-01
Penata III C Joho Lor R F 331212541176K 0 Ass.Apotek21-100-01
Penata MudIII B WonokartoF 331212530160K 1 Pelaksana 21-100-01
Penata MudIII B Joho Lor R F 331212590365TK 0 Pelaksana 21-100-01
Penata MudIII B Manggis RTM 331213061082K 2 Perawat P 21-100-01
Penata MudIII B Setro RT 0 M 331212280481K 2 Perawat P 21-100-01
Penata Mu III A Gemutren RF 331211670782K 1 Bidan Pela 21-100-01
Penata Mu III A Per.GedongM 331312040674K 2 Fisioterapi 21-100-01
Penata Mu III A Jl.Arjuna I F 331015650686K 2 Bidan Pert 21-100-01
Penata Mu III A Perum Mega F 331219550884K 2 Bidan Pela 21-100-01
Penata Mu III A Perum CiptF 331023710587K 2 Perawat Gig21-100-01
Penata Mu III A Begalon RTF 337201521082K 1 Nutrisionis 21-100-01
Penata Mu III A Sukorejo RTF 331212530181K 2 Pranata Lab21-100-01
Pengatur TkII D Griya Giri F 340203700983TK 0 Pranata La 21-100-01
Pengatur TkII D Perum PokoF 331212461175TK 0 Ass.Apt.Pe 21-100-01
Pengatur TkII D Jl. Cempak F 331212450577TK 0 Bidan pela 21-100-01
Pengatur TkII D WonokartoF 331212440875K 2 Bidan pela 21-100-01
Pengatur TkII D Jl. Yudhis F 331212460375K 2 Bidan pela 21-100-01
Pengatur TkII D TambakrejoF 331102450476K 0 Bidan pela 21-100-01
Pengatur TkII D Pokoh RT 0F 331215560280K 2 Bidan pela 21-100-01
Pengatur II C Joho Lor rt F 331212461126K 2 Pengadmini21-100-01
Pengatur II C Salak RT 0 F 331212430983K 2 Bidan 21-100-01
Pengatur II C Kaloran RT F 331212501285K 2 Bidan 21-100-01
Pengatur II C Pengkol RTF 331212490983TK 0 Bidan 21-100-01
Pengatur II C Kaloran LorF 331111530786K 1 Bidan 21-100-01
0 0 0F 0 0 0 0 21-100-01
- - 0F 0 0 0 0 21-100-01
- - 0F 0 0 0 0 21-100-01
- - 0F 0 0 0 0 21-100-01
- - 0 F 0 0 0 0 21-100-01
- - 0 F 0 0 0 0 21-100-01
- - 0 F 0 0 0 0 21-100-01
- - 0 F 0 0 0 0 21-100-01
- - 0 F 0 0 0 0 21-100-01
Jumlah 1 Jumlah 2 Jumlah 3 Jumlah 4 Jumlah 5 Jumlah 6 Jumlah 7 Jumlah 8 Jumlah 9 Jumlah 10
57093400 0 0 57093400 0 6480000 869040 0 0 0
49393400 4939340 1975736 56308476 0 5880000 3476160 0 0 0
68072200 6807220 1361444 76240864 0 14400000 2607120 0 0 0
68072200 6807220 2722888 77602308 0 14400000 3476160 0 0 0
55930000 5593000 2237200 63760200 0 14400000 3476160 0 0 0
47399800 4739980 1895992 54035772 0 14400000 3476160 0 0 0
45476200 4547620 0 50023820 0 9000000 869040 0 0 0
58280600 5828060 2331224 66439884 0 6000000 3476160 0 0 0
60746000 6074600 0 66820600 0 10200000 869040 0 0 0
56501200 5650120 1130024 63281344 0 6000000 2607120 0 0 0
56501200 0 1130024 57631224 0 6000000 1738000 0 0 0
54776400 5477640 1095528 61349568 0 6000000 2607120 0 0 0
45476200 4547620 0 50023820 0 7200000 869040 0 0 0
45476200 4547620 909524 50933344 0 7200000 2607120 0 0 0
45476200 4547620 1819048 51842868 0 7200000 3476160 0 0 0
46908400 4690840 1876336 53475576 0 7200000 3476160 0 0 0
47884200 4788420 0 52672620 0 6000000 869040 0 0 0
0 0 0 0 0 0 0 0 0 0
53646600 0 0 53646600 0 2220000 869040 0 0 0
40581800 4058180 1623272 46263252 0 3600000 3476160 0 0 0
40581800 4058180 1623272 46263252 0 3600000 3476160 0 0 0
40161800 4016180 803236 44981216 0 3180000 2607120 0 0 0
37746800 3774680 1509872 43031352 0 3180000 3476160 0 0 0
37746800 3774680 1509872 43031352 0 3600000 3476160 0 0 0
36593200 3659320 1463728 41716248 0 3180000 3476160 0 0 0
36593200 3659320 1463728 41716248 0 3180000 3476160 0 0 0
36593200 3659320 731864 40984384 0 3180000 2607120 0 0 0
40161800 4016180 1606472 45784452 0 3180000 3476160 0 0 0
36593200 0 0 36593200 0 3180000 869040 0 0 0
43619800 0 0 43619800 0 2880000 869040 0 0 0
40996200 0 0 40996200 0 2880000 869040 0 0 0
42288400 4228840 1691536 48208776 0 2880000 3476160 0 0 0
42288400 4228840 1691536 48208776 0 2880000 3476160 0 0 0
36213800 3621380 0 39835180 0 2880000 869040 0 0 0
37354800 3735480 1494192 42584472 0 2880000 2607120 0 0 0
41850200 4185020 1674008 47709228 0 2160000 3476160 0 0 0
18431280 1843128 737251.2 21011659 0 1620000 3476160 0 0 0
17868960 1786896 714758.4 20370614 0 1620000 3476160 0 0 0
18431280 0 0 18431280 0 1620000 869040 0 0 0
17868960 1786896 357379.2 20013235 0 1620000 2607120 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Jumlah 11 Jumlah 12 Jumlah 13 Jumlah 14 Jumlah 15 Jumlah 16 Jumlah 17 Jumlah 18 Jumlah 19 Jumlah 20
64442440 3222122 2711936 5934058 58508382 0 58508382 54000000 4508382 225400
65664636 3283231 2674652 5957883 59706753 0 59706753 67500000 0 0
93247984 4662399 3621441 8283840 84964144 0 84964144 63000000 21964144 1098200
95478468 4773923 3686109 8460032 87018436 0 87018436 67500000 19518436 975900
81636360 4081818 3028609 7110427 74525933 0 74525933 67500000 7025933 351250
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0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
Jumlah 21 Jumlah 22 Jumlah 23 Jumlah 23aJumlah 23bStatus Pin NPWP Pemotong Nama Pem Tanggal Bukt
0 225400 225400 225400 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 1098200 1098200 1098200 0 000000000000000 SRI MARLI 1/10/2017
0 975900 975900 975900 0 000000000000000 SRI MARLI 1/10/2017
0 351250 351250 351250 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 73200 73200 73200 0 000000000000000 SRI MARLI 1/10/2017
0 616050 616050 616050 0 000000000000000 SRI MARLI 1/10/2017
0 114400 114400 114400 0 000000000000000 SRI MARLI 1/10/2017
0 43150 43150 43150 0 000000000000000 SRI MARLI 1/10/2017
0 27200 27200 27200 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
0 0 0 0 0 000000000000000 SRI MARLI 1/10/2017
Instansi P NIP Pemotong
UPT PUSKE ###
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UPT PUSKE ###
UPT PUSKE ###
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UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
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UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
UPT PUSKE ###
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