PERNYATAAN

PERNYATAAN PERUBAHAN
PENSU ARMABTAPNOMOR
HEARN REKENING (INDIVIDU)
YNPERNYATAAN
AOTAMAOFORMULIR
NRPERUBAHAN
DRAENKE KNUNOMOR
IANSGAREK
PERUBAHAN
(PERUSAHAAN)
DATA
ING
Kepada Yth,
P.PYT.Ta..S..Sn.ini.ng.a.ar.rbm.m.e.a.asr.s.tS.Saee,knku.du.r.ria.tit.ata.sa.s.n..g..a..n...d..i.b..a..w...ah ini :
KPPelalpazazadaBaBIYIItT,Thoo,wweerrIIIILLtt55

…..SM…MinH…Ha.r.Tm…Thhaa…sammS…reri…kninuK…rKaitav.av.s5.5.1.1,.,.JJ.aa.k.ka.a.r.rt.ta.a.1.10.0.3.35.5.0.0.........................., sesuai
PJJTll
Kepad
Up : Direksi PT.Sinarmas
Nomor
PT.SinarmasKTP. …....................................................…………….
PU lap za: B DIi Ir,Te okws i eP rT .ISII inL tar5 ma s Se ku
b e r d o m i s i li d i … … … … …
rit a s
. .. ..........................................................................................................................................
Jl . M H . T ha m r i n K a v 5 1 , J a k a r t a 1 0 3 5 0
. . ... … … … . . . .. .. . .. .. . .. . . . .. . . .. . .. .. . ......................................................… RT……. / RW……. untuk
HPalla:
selanjutnya keduanya
H al : P e r u b a ha n N o m o r R e k e n i n g
U p : D i r e k s i P T . S in ar m a s S e k u r it a s
Jdl.isMebHu.tTPheammbrienriKPaevr5n1ya, tJaaakanrdtaan10K3u5a0sa.
Dengan hormat,
U p : B a g i a n A d m in is t r a s i A sset
Y Daen ng gba enr th aon r dma atat ,ng a n d i b a w a h i n i :
Management.
H al : Pe na m baha n N o m o r R e k ening
P e m b e ri P e r n y a t a a n dan Kuasa ini menyatakan bertindak selaku pemilik
Saya yang bertandatangan di bawah
dalam hal
… …
I. N am a … ............... : .. . . .. . . .. . . .. . . .. . . .. . . .. ...........................…...…....
.. . . . . . . . . . . . . . . . . . . . : ............................................................................
….........d...i...P...T.....S...i.n...a. rmas SeIIk. uNraimtaas.
DeAnglaamn : ............................................................................. Alamat : .............................................................................
ahtormat,
PNeamriahal: Peruba:h..a...n....D...a..t..a....N...a...s..a..b...a...h.............................................................................................................................
SeAhlaumbuatngan
dengan:...a....d....a....n....y...a........d....a....n....a........k...a....m......i......d....i......P....r...o....d....u.....k........................................................................................
..........................................................................................................................................................................................................
No. Identitas : ............................................................................. No. Identitas : .............................................................................
dengan
NPoenomor .m Id investor......................................................................................................................................yang
eb ne tirtia sP e r n ya : .t.a...a..n....d...a...n....K..u...a...s..a....d..e...n...g..a...ndikelola ....i.n...ioleh
..m....PT.e...
Sinarmas
n...y..a..t..a...k..a.
.n....d...e
D a...nn....m g ....: ae.............................................................................
..mn.....b..he...ro..i..rk... mu..aa...st..a, ....k..e...p..a...d...a...:................
Jabatan Jabatan :
(selanjutnya disebut ”Produk”) , maka bersama ini kami yang bertandatangan di bawah ini:

DSNealamkuapemilik sah a:ta…s p…ro…d…uk…...…....…...…................................................................................................................................

I.B
NaNeola
a.rm sam
mInv haal.........
aestor: dine:..i.n...b..g...e..a..r.n .......s..a.u
...tind ...k..ra
....d..t..a..i.l.n .....i,.....s..j.a..ab
...am ....y
...a.a
...t./..an
....k
...n..a..y..m
....a....i..t.y ...a
...er ...s.n ....g..ut
...eb ....be
.....d..r..ia
...t.t..a..a..n
...s,..da
......ole than/kgNaIIao.remnNna
............ diritbuaws
oam
KaPT...................
onfirmasi pe:m..b..e..l.i.a..n..:......................................................dan .......selaku
...........pemilik
............sah.......atas
.......produk
...............................
pNroodKuTkP ............:..…...…...…..…...…...…...…..
…............................................................................................................................................a..t.a..s...:.......................
..............
teA rl taa m ga gt a l . . .. . . . . . .......:...........................................................................................................................................................................
.........o...........I....n..v......e.....s...t./o...r.N: .........o.......m
N ... ..r..K..o..n...fi..r.m...a.A.s.l.ia.p.m.e..am..t..b..e..l.ia. nd:i
P..T....:.S...i..n....a....r...m......a....s.....S...e..o ..k....u....r...i.t...a....s.....(..s....e...l..a....n....j..u....t...n....y....a.....d....i..s...e....b....u....t.....”...P....r...o....d....u.....k
”.).
Alamat : ……………………..................................................................................................................
tDerikt aregngakl
an..................................................................................................................................................................................................d..i....P..T.....S..i.n..a..r.m....a
...s........S....e....k...u....r...i..t...a....s........(..s....e....l.a....n....j..u....t...n....y....a.........d....i..s...e....b....u....t........”.........P....r...o....d....u....k....”...)...
DNiNkaaomr.eIndaaeknatinta.s..........:.:........…........….......….......…........…......…........….......
….................................................................................................................................................................N.....o........I..d....e...n....ti...t..a....s..
..............:.........................................................................................................................................................................................................
NDJJaeaobnb.gaaaIttnananvinnei smteomr be:r:i.:t..a…..h..u…..k.a.….n..….b..a.….h..w.…..a.
…..s..e…..g.a....l.a......p...e....n...c...a....i..r..a...n.....d....a...n....a.....d...a....r..i...P....r..o...d...u.k..t.e..r.s.e..b.u..t.Jd.a.ib.a.ta.at.sa..ny.a..n.g...s
.e.m...u.l:.a....m.....e....l.a....l..u...i...r..e....k...e....n...i..n...g......-.r..e....k...e....n...i..n....g.....s..e...b....a...g....a...i..b..e..r.i.k..u..t.:.......
Dengan ini memberitahukan bahwa segala pencairan dana kami dari produk............................yang semula melalui rekening -rekening sebagai berikut:
Dalam
No hal Nama ini bertindak
Pemilik Rekening dalam jabatannya tersebut Nomor Rekening diatas, oleh karena itu sah Bankdan berhak bertindak untuk dan atas nama
Selanjut
1No Nama..n...Pemilik
y..a....dRekening
...i.s..e...b..u...t...s..e...Nomor b...a..gRekening
...a..i...“..P..e...n...e..r..i.m..aBank ....P...e..r..n...y..a...t.a...a..n....d...a...n....K..u...a...s..a..
P
”.D.. T.. a
...... .. r .. i ... s .. e .. b ... e ... l . u ...
..........................................m .... n... y .. a ..... :............................................................................................... bermaksud..........................................
menambahkan nomor
1 ............................................................. ............................................................. .......................................... ..........................................
2 ............................................................. ............................................................. .......................................... ..........................................
2Produk ters ..e..b..u..t...d..i.a..t.a..s..k..e...r.e..k..e..n..i.n..g..-.r.e..k..e..n..i.n..g...d..i..b. a ...a..h...i.n..i.:................................................. ....................................
...... ..........................................
No NAamlaamPeamt ilik Rekening N:omor Rekening Bank Cabang
K Pa me mi r u bb ea rh ia Pg ae r rd na yp aa tt ad ia t r na n ds f ae rn k e Kru e ak e sn aiinndgg--
S a ya r u b a h a g a r d a p a t d i t r a n s f e r k e r e k e n
1............................................................................................................................................................... Kode
rree kk een nii nngg b baa rruu sse ebb aa gga aii bb ee rr iikk uutt::
e n g a n in i m e n y a t a k a n dan memberi kuasa kepada
Pen...e..r..i.m.....a....P..e...r..n..y...a..t..a..a...n ..............................................................................................................dan
N N N N a m a P e inmgiliil N oe m or R B a CCaabbaanngg
oo kikRaRemekkaeePnneinm g N
eekokem nno ininr gRg B
nnkak
2Kuasa .u.N..n..o.t...u..tk..e..l.m.e..p.e..o.n..n.e..r./.i.m.H...P.a....s..e...g..a...l.a.....m....a.
c.a.:..m......s..u...r..a..t....m....e...n..y...u...r.a...t....y..a...n..g.....d...iki.r..i.m.....k..a..n.....o...l.e...h.....P..T.......S..i..nar..m....a...s....S..e...k..u
...1r..i.t..a................................................................
. s k e p ada
.... .. ... ..
1 .............................................................. ........................................... ...........................................
PemberEimPearilnyataan dan Kuasa. :
22 .............................................................. .............................................................. ........................................... ...........................................
Dikarenaka n. ... . .. ..... ... . .. ........................................... ...............................................................................................................................................
.............. A h l i W a r i s :
DDPeeemmmikikibaianenirLniinaffoPoirnermmnranayssiyaiianin.it.id.as.iaa.s.yan.am..s.dpa.a.am.ik.np.a.an.Ki.ks.ua.e.nah..uss.eba.h
uumnbgauenngdya:eannddgaeanrgipaednraupbnearuhmbanaehrnaenekerrneimiknegnauinnsgteuugknatpuleaknpckaeoinrnacnasiredaak

nnudaeadnnaarsidiPahrroiudPkurokudtmuerksyteeabrunsetgbduitiattmdasia.btausl. sehubungan
DdemenikgiaanninfPoermrnasyiaintiadaisnamdpaanikaPnesmehbubeurniagann Kdeunagsaan .penambahan rekening untuk pencairan
dana dari Produk tersebut diatas
Bersama ini kami menyatakan bahwa:
Bersama ini saya menyatakan bahwa:
1.Menjad
Apabila di kemudian hari terjadi perubahan susunan kepengurusan, perubahan nama karena adanya merger atau corporate action lainnya, maka
B1Pe.resSamamyaba ebiner irikh aP amke irdm nan yenasyatahataauknnatnudkbaabnhewrtiKanu: daaskaatmas ennamy aa
A l a m aSinarmas
t :
tsaekami
kndaakan
inri ssegera
bearthmemberitahukannya
a wbearwmeneankepada
ngepriePT.
mnu ah,sdeaSekuritas,
gnatildaaktetapi
remsapabila
eikmokarena sesuatu
eryluakanngptihal
erm kami lalaijuuntuk
sebtu u laan
kdiabriaptihkaektmeralnaampubn autnatunk
1.
pAkemepnpeaaelbadirklaaiumPkdaTia.nSkaiepnnmearrusumdubiaaarshanaSthnemaknruoiremtitenaorysjra,urdserei
kahpetienrtgiunegbgaraushmneatebnunkugppat dedianbacasatntkirrauamnkntehuParrnolp-
:
gdheauarklukysutaeaihnrssageaebtinrudttkaaadkmimaditiiaetnsegn,rimdneekarnasingmuakdnaatielnsatimaespmaiRytieaudkmaeankeKhilnt
e aegp rlabPy sarkaota adnns ugdkp aattndeearmrstepeebemruraubt beddabihaaidtasaknasa,lpnamesmmaekleuasgruaubnhergarkstas
o d e P o s
aarmyyhaaawmninag,ni

dpk ideakarmiunrbiiDmmaihrekae s nnkad yaosnr ai .stiPaus otTekse.lgauaeSllnaeihnamtpaunPrenomt lTuken.taepaspSna/ b a i k d

esSi nkneagka nurrdmuitasanaaN nsm , Se pme e kbr ueu b ra i thskaa a nsn k sn eea lp mu raau dh ka ka arPr eyenaaramwi
H P :
pabainhdeadrnaiynyPaaDenimgrrenbekyersgriaewPtrTea.nSaaaitnnnaagurdmacaaonsnrpaSKpeoukurauantrseiatakaiasbtcdeatitarorasnides
aeblnaguyainaltan.Pyteaum,ntbmuat aaaknlabnakdiakamndiaPreai rkpuaibhnahksaeknegtieargt a s

mmSeuamruapbtuePnrietdranahryuiakptaihnaankytayeakrndegaphbaudelrauwPedTna.SaninbaermmrsaanmsaSapeuiknuiarsiktaiabysa,
ttmeadteaE anpm
nyiyaaata
i plpkaeabnilcaateikrtaarnpeanbtaaeur : stehasnaulgaagtpuanhpgaujalnwkyaambnigsleadclialairkauunpktaruinbkadmdaileaampba
rebersama
beriklieatainnhaind
i k agam Pt
u ka n
i menyatakan
ruon
n tetap bertanggun gjawab secara pribadi dan tidak akan melakukan tuntutan apapun kepada
y a k e p a d abriuPptTid.hSiaianktarskmedtiagsna
dt ut a tne r ds ea
Setekruhraitdaasp, sPeTh.iSnigngaar mesnSgeakuibraittaksa.n hal-hal yang tidak diinginkan dalam Rekening Produk kami tersebut diatas, maka
Berdasa
bersama
menyatakan Arhdengan
ini kamiklmenyatakan
ainWhaarl2.istersebut,
Sehubunganmaka denganPem
:beri
adanya Pernyataan
surat danbeserta
pernyataan ini Kuasa dengan
segala akibatini menyatakan
hukumnya maka dengan ini kami
2. Sehubungan adanya surat pernyataan untuk ini maka dengan melepaskan
ini saya menyatakan melepaskan dan membebaskan seluruh karyawan dan dan
dmmaenelLainnyamepkbaae.........................
sbrkyanakwdanaansnemluePrmTubheSkbianarsyakarawmnasnaelsduarSnuehDkkirauerrkyisatiwaPasTn.
dSdiaannrairDmisraeeskgsSaiePlkaTu.SrtiitnuaasnrmdtuaartsiaSsnekuahlrauitatkusundmtaurtiaspneighbaaaliakktdumanrtiuaptnaihnaa
pbkaukiknetidgsaarei hmpiuahubapkuuknnetigpgaihanamkdayueapnnuggnbadenarrwiSepuniharanakgt
PT. Sinarmas Sekuritas dari segala tuntutan baik dari pihak ketiga maupun pihak yang berwenang manapun akibat adanya surat pernyataan
ymanagnabpeurnweankaibnagt madaannaypaunsuarkaitbaptearndyaantyaaanpeincadiarannbaetrasuamhaal
aPernyataan
inpiakpaumniymdan anegnyKuasa
dailtaakkini.
uaknanSurat
tedtalam Pernyataan
beretaknenggdan
inugnPKuasa
g rjoadwuini berlaku
akbte sresceabrasampai
utpdriiabtdengan
aadsi daapnadanya
a belarsamSurat
daa tiunni
tkuatmani perubahan nomor rekening ini dan bersama ini saya menyatakan tetap bertanggung jawab secara pribadi apabila ada tuntutan
m t e r h a d a p
e n y a t a k a n te t a p P T . S i n a r m a s S e k u r i t a s
b e r ta n g g u n g j a w a b se c a ra. pri b ad i
KDemikian
u a spermohonan
a y a perubahan
n g d iinitkami e rajukan,
i m dan a kamio menyatakan
l e h P bertanggung
T . S i n a rm a satas
jawab S segala
edaknutirditaaksa.kan melakukan tuntutan apapun kepada PT.Sinarmas Sekuritas.
2.
Sehubungan dengan adanya Surat Pernyataan ini beserta segala akibat hukumnya maka dengan ini kami menyatakan melepaskan dan
yang timbul
...................... sehubungan dengan adanya perubahan data tersebut
, .............................................
…Dm…ee…mm…
bHormat
i.k.e.i.b.a.a.n.s.k..aS..n.u,sr.ea..lu.t..r.Pu..he...rk..na..ry.y..aa..wt..aa..na...nd..a..dn...aD..n.i.r.eKkusi aPsT.aSininarimdaisbSueakutrditaes
ndgaarinsesgealba etunnaturtnaynabadikadnardi ippihearkuknetitugakmkaaunpgunudnaari ppiehnakeyraimngabaernwSenuarnagt
m a n a p u n a k i ba t a d an y a S ur at p e n a m b a ha n n o m o r
HHy aoor nrm mg a tda sita kyk iara ,i mm k i, a n o l e h P T . S i n a r m a s S e k u
rreitkaensinkgeipnia. da Pemberi Pernyataan dan Kuasa.
........................ , .......................................
H…or…ma…t .k.a.m...i,............…, ………......................……………..
Materai Rp 6000,-
Materai Rp 6000,-
PembeMriatPeerarinRypa6t0a0a0,n- dan Kuasa, Penerima Pernyataan dan Kuasa
((.......................................................)...............)
(...............................) (...............................)

(...............................) (...............................)

Materai Rp. 6000

(............…….................………..) (............…….................………..)
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: j I t i
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