1. |
Nama Pengusaha/Importir |
: |
.................................................................................... |
2. |
Nama Perusahaan |
: |
................................................................................... |
3. |
Alamat Perusahaan |
: |
................................................................................... |
4. |
Nomor & Tanggal S.I.U |
: |
................................................................................... |
5. |
Yang Diberi Kuasa |
: |
................................................................................... |
6. |
Cara Pembayaran |
: |
|
7. |
Jenis Barang Kena Cukai |
: |
................................................................................... |
|
|
8. |
Tarif Cukai |
: |
|
Seri |
M e r e k |
Isi/
bks |
HJE
(Rp) |
Lembar |
Jumlah HJE
Lbr x HE x Seri |
Jumlah Cukai
Jml HE x % Tarif |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
|
|
|
|
|
|
|
Jumlah Total |
|
|
|
|
10. |
Dikurangi pengembalian cukai sesuai CK
... Nomor ......... Tgl ....... |
|
Jumlah cukai yang seharusnya dibayar |
|
|
11. |
Pungutan lain
a. |
PPN |
: |
................................................................................... |
b. |
PPnBM |
: |
................................................................................... |
c. |
DCU |
: |
................................................................................... |
d. |
Lain-lain |
: |
................................................................................... |
|
12. |
Catatan Petugas
Nomor
....................... |
Diserahkan
Pita Cukai |
Tanggal
....................... |
Paraf
....................... |
|