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POWER OF ATTORNEY
FOR CLAIMING TAX REFUND OF INDONESIA TAX WITHHOLDING (FORM - DGT 4)
The undersigned :
Name : (1)
Address : (2)
Phone No. : ( )
Address : (6)
Phone No. ( )
Country/Jurisdiction : (7)
Address : (10)
Phone No. ( )
to lodge the application for claiming tax refund of Indonesia tax withholding (completed Form-DGT 3), including the required
attachments, to the Director General of Taxes, and to act on my behalf to receive the tax refund approved by the Director
General of Taxes.
, / / (11)
Place and Date (mm/dd/yyyy)
Signature of the proxy Signature of the claimant or individual Capacity in which acting
authorized to sign on behalf of the claimant
FORM-DGT 4