| DEPARTEMEN KEUANGAN REPUBLIK INDONESIA |
| DIREKTORAT JENDERAL BEA DAN CUKAI |
| KANTOR .............................................................................. |
SURAT BUKTI PENINDAKAN
Nomor :
| Yang bertanda tangan di bawah ini : |
| Nama | : | ................................................................................................................................................................................... |
| NIP | : | ................................................................................................................................................................................... |
| Pangkat | : | ................................................................................................................................................................................... |
| Jabatan | : | ................................................................................................................................................................................... |
| Berdasarkan Surat Perintah Penindakan Nomor .................................. tanggal ............................... telah melakukan penindakan berupa penghentian / pemeriksaan / penegahan / penyegelan *) terhadap : |
| Barang Kena Cukai | : | ................................................................................................................................................. |
| Sarana pengangkut | : | ................................................................................................................................................. |
| Bangunan atau tempat lain | : | ................................................................................................................................................. |
| Pembukuan | : | ................................................................................................................................................. |
| Uraian pelaksanaan penindakan dan alasannya.................................................................................................................. |
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Pengangkut/Pemilik/Kuasanya, |
Pejabat Bea dan Cukai |
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NIP ...................................... |
*) coret yang tidak perlu