FORMULIR PENERIMAAN UANG - RECEIVE MONEY FORM

Mohon lengkapi bagian ini dan tunjukkan Kartu Tanda Penduduk / Pasport yang sah
Please complete this portion of the form and present with valid Identification Card / Passport
1. D A T A P E N E R I M A / B E N E F I C I A R Y ‘S P A R T I C U L A R S 4. D I I S I O L E H B A N K / A G E N
Nama Tempat / Tanggal Lahir FOR BANK / AGENT’S USE ONLY
N ame .............................................................................................................................................................................................................................. Place / Date of Birth ........................................................ TANGGAL
No. KTP / Paspor Jenis Identitas Jenis Kelamin Perempuan Lelaki DATE
I.D. / Passport No. ID Type ........................................................................... Gender Female Male JUMLAH PEMBAYARAN (IDR)
Alamat ....................................................................................................................... Warganegara PAYOUT AMOUNT (IDR)
Local Address ......................................................................................................................................................................................... Nationality .........................................................................
Kode Pos Negara
...............................................................................................................................................................................................................
Postcode ................................ Country .........................................................................

Penduduk Bukan Penduduk

Pekerjaan No. Telp. / Handphone Jumlah yang dikirim Pengirim dalam Mata Uang Asal
Resident Non Resident Amount Sent by Sender in Original Currency
Occupation ................................................................................................................. Phone / Handphone No. .................................................
Nama Perusahaan Tempat Bekerja Jenis Usaha
… …Name
Employer’s … … ........................................................................................................................... Nature of Business ...........................................................................................................................
2. D A T A P E N G I R I M / S E N D E R ’ S P A R T I C U L A R S NILAI TUKAR MATA UANG SETEMPAT
Nama No. KTP / Paspor RATE LOCAL CURRENCY
Name ............................................................................................................................................................................................................................................... I.D / Passport No. ..................................................................
Alamat No. Telp. / Handphone
Address .................................................................................................................................................................................................................... Phone / Handphone No. ......................................................... NO. TRANSAKSI CMT
Kodepos Negara CMT TRANSACTION ID
........................................................................................................................................................................ Postcode ................................. Country .................................................................................. KODE AGENSI / ID TELLER
3. K E T E R A N G A N P E N E R I M A A N U A N G / P A R T I C U L A R S O F M O N E Y R E C E I V E D AGENCY CODE / TELLER ID
Jumlah Yang Diperkirakan BOP - KODE TUJUAN
Expected Amount Received Rp. .................................................................................................................................................................................................................................................... PURPOSE CODE
Uang dikirim dari Kota / Provinsi / Negara Kota Negara KODE KONSTITUSI
The Money Sent from City, State / Province, Country City .................................................................................
.............................................................................................................................................................
Country CONSTITUTION CODE
Kode Pembayaran CIMB Money Transfer KODE NEGARA PENERIMA
C M T
CIMB Money Transfer Tracer No. BENEFICIARY’S COUNTRY CODE
Tandatangan Penerima
Cutomer’s Signature Penerima menyatakan bahwa telah membaca dan memahami syarat dan ketentuan yang terlampir dibelakang formulir ini
(”Syarat dan Ketentuan”) / The Receiver hereby declares that has read and undestood the terms and conditions set forth
on the reverse of this form (”Term & Condition”)
Bea Meterai
Stamp Duty Penerima setuju untuk menanggung seluruh kerugian, biaya, pengeluaran, ganti rugi, tuntutan, permintaan, permintaan,
tindakan dan/atau biaya lain yang dikeluarkan oleh Bank dalam rangka memenuhi ketentuan perundang-undangan, yang
mungkin timbul akibat permohonan ini dan dengan ini Penerima bertanggungjawab terhadap keaslian semua dokumen
yang diberikan kepada Bank. / The Receiver agrees to indemnify the Bank against any and/or all loss, costs, expenses,
damages, claims, demands, actions and/or proceedings, which may arise in consequence of this application or document
Tanggal pursuant to this application and is fully responsible for the originality of documents given to the Bank.
Date .........................../............................../............................. TANDA TANGAN AGEN
Agent’s Copy AGENT’S SIGNATURE