This document is an annual tax return form for an individual Indonesian taxpayer for the year 2021. It requests information about the taxpayer's income, deductions, tax credits, and tax liability. Key details include the taxpayer's name (Veronica Lindawati) and identification number, sources of income including from employment and other domestic income, personal exemptions amount, payable income tax amount, tax withheld by other parties as a credit, and attachments required including proof of withholding and tax payment receipts. The taxpayer declares that the information provided is true and complete.

1. FORM
1770 S
FINANCE MINISTRY
OF EPUBLIC OF
INDONESIA
DIRECTORATE
GENERAL OF TAXES
ANNUAL TAX RETURN
INCOME TAX OF INDIVIDUAL TAXPAYER
TAXABLE
YEAR
2 0 2 1
FOR TAXPAYER WITH INCOME:
• FROM ONE OR MORE EMPLOYER(S)
• FROM OTHER DOMESTIC
• INCOME SUBJECT TO FINAL AND/OR
FINALIZED TAX
ANNUAL TAX RETURN
CORRECTION
FOR THE 0 TIME
ATTENTION:
• FOLLOW INSTRUCTION IN THE MANUAL • PRINT OR TYPE WITH CAPITAL LETTER AND BLACK INK
• MARK " X " IN THE APPROPRIATE BOX
IDENTITY
TAXPAYER ID NO. : 45.677.511.3-606.000
TAXPAYER’S NAME : VERONICA LINDAWATI
OCCUPATION : PRIVATE EMPLOYEE KLU: 96304
TELEPHONE NO. : 0-0
STATUS OF HUSBAND AND
WIFE TAX OBLIGATIONS KK HB PH MT
TIN OF HUSBAN/WIFE
Application of data changes submittedseparately from reporting Annual Tax Returnof Personal Income Tax, by using Data
Amendment Form of Taxpayer and completed by the required documents
*) The filing columns of Rupiah value must be w ithout decimalvalue (see example in page 3 of instructions)
A.
NET
INCOME
1. DOMESTIC NET INCOME RELATED TO EMPLOYMENT
[Filled w ith totalaccumulation of net income in attachment of Form 1721-A1 and/or
1721-A2 number 14 w hich is attached]
1 797,482,158
2. OTHER DOMESTIC NET INCOME
[From Form 1770 S- I Total Part A]
2 0
3. FOREIGN NET INCOME
[Complete it fromseparate attachment if any foreign income, see instruction book]
3 0
4. TOTAL NET INCOME (LINE 1 + 2 + 3 ) 4 797,482,158
5. ZAKAT/OBLIGATED CHARITY 5 0
6. TOTAL NET INCOME AFTER ZAKAT/OBLIGATED CHARITY (4-5) 6 797,482,158
B.
TAXABLE
INCOME
7. PERSONAL EXEMPTIONS TK/ k K/ K/I/
7
54,000,000
8. TAXABLE INCOME (6 -7)
8 743,482,000
C.
PAYAB
LE
INCOM
E
TAX
9. PAYABLE INCOME TAX (TAX RATE ON ARTICLE 17 x LINE 8)
[For Taxpayers with PH or MT filled status of Appendix Calculation of Income Tax
Payable referred to in section G: Appendix point d]
9 168,044,600
x
2

2. 10. RETURN/REDUCTION OF CREDITED INCOME TAX
ARTICLE 24
10 0
11. TOTAL PAYABLE INCOME TAX (9 + 10) 11 168,044,600
D.
TAX
CREDIT
12. TAX WITHHELD BY OTHER PARTY/BORNE BY
GOVERNMENT AND/OR CREDIT OF FOREIGN TAX/UNPAID IN
OVERSEAS [Filled fromForm 1770 S-I Total Part C Column (7)]
12 168,044,600
13. a. INCOME TAX SHALL BE PAID
b. INCOME TAX OVERLY WITHHELD (11-12) 13 0
14. PREPAID TAX: a. INCOME TAX ARTICLE 25
b. Notice Of Tax Collection On Income Tax Article 25
(Principal Only)
14a 0
14b 0
15. TOTAL TAX CREDIT (14a+14b)
15 0
E.
INCOME
TAX
OVER/UNDER
PAID
16. a. UNDERPAID TAX (INCOME TAX ARTICLE 29)
(13-15)
b. OVERPAID TAX (INCOME TAX ARTICLE 28 A)
SETTLED ON : DATE MONTH YEAR
16 0
17. REQUEST: Overpaid amount stated in 16.b w ould be
a. REUNDED
b. COMPENSATED WITH PAYABLE TAX
c. REFUNDED WITH SKPPKP ARTICLE 17 C (Taxpayer With Certain Criteria)
d. REFUNDED WITH SKPPKP ARTICLE 17 D (Taxpayer Fulfilled Certain Criteria)
F.
MONTHLY
INSTALLMENT
OF
INCOME
TAX
ARTICLES
25
FOR
THE
SUBSEQUENT
YEAR
18. INSTALLMENT OF INCOME TAX ARTICLE 25 FOR THE
SUBSEQUENT YEAR IS
CALCULATED BY:
a. 1/12 X THE TOTAL OF POINT 13
b. CALCULATION IN SEPARATE ATTACHMENT
18 0
G.
ATTACTMENT
a. Copy of Form 1721-A1 and/or 1721-A2 of withholding proof
of Income Tax Article 21
b. Third Copy Of Tax Payment Receipt Of Income Tax Article 29
c. Special Power Of Attorney (If Needed)

3. d. Payable Income Tax Calculation For Taxpayer With Tax
Status of PH or MT
e. -
DECLARATION
Understanding all the sanctions provided by the law and regulations, I hereby declare that the information
stated in this return, including all attachments provided, are true, complete, and clear.
TAXPAYER REPRESENTATIVE DATE 22/03/2022 SIGNATURE
FULL NAME : VERONICA LINDAWATI
TIN : 45.677.511.3-606.000
x