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WRITE OFF REQUEST FORM

Company Name:
Department:

A. ACCOUNTS RECEIVABLES/OTHER RECEIVABLES


Customer Name/Counterparty:
Customer/Counterparty Address:
Services/Goods Provided:

Details of related receivables*


Invoice No.: Due Date: Days o
Total Net Amount: Total PPN: Total v
Justification for write-off: Unable to locate/contact customer Others. Please specify _______
Bankruptcy of customer (proof attached)
B. FIXED ASSETS AND OTHER ASSETS
Type of Asset: Land Machinery & equipment Furnitures & fixtures Intangi
Buildings Installation & Equipment Tools & moulding Others
Building improvements Vehicles Computer software
Asset Description:
Asset Location:
Year Acquired/Booked: Cost of Asset:
Resale value: Gain (Loss):
Justification for write-off: Obsolescence Loss
Destruction/Damage Others. Please specify. _____________________
C. INVENTORY
Type of Inventory: Raw Materials Work-in-progress Finished Goods
Inventory Description:

Description of related inventory*


Unit Code: Quantity: Unit Cost: Total Valu
Resale value: Gain (Loss):
Justification for write-off: Obsolescence Loss
Destruction/Damage Others. Please specify. _____________________
D. ACCOUNTS PAYABLE AND OTHER LIABILITIES
Supplier Name/Counterparty:
Supplier/Counterparty Address:
Services/Goods Purchased:
Details of related payables*
Invoice No.: Due Date: Days o
Total Net Amount: Total PPN: Total v
Justification for write-off: Long outstanding accrual Debt restructuring
Disputed balance Others. Please specify. _____________________
E. APPROVAL - PC LEVEL
Requested by: Verified by: Approved by:
Requestor Finance & Accounting Director

F. APPROVAL - MACOM LEVEL


B.O. MACOM MANAGEMENT COMMITTEE
Checked by: Approved by: Approved by:

Finance and Acounting original Department copy B.O. M


Please distribute the documents to related department as mentioned above
* Detailed list of transaction/invoices/inventory/payable can be attached with this form.
IMPORTANT:
Fixed Assets > Net book value/item Rp 500 million and below, approval up to PC level
Net book value/item above Rp 500 million, approval up to MACOM leve
Receivables/Payables, Inventories > Rp 50 million and below, approval up to PC level (complete Section E)
and Other Assets Above Rp 50 million, approval up to MACOM level (complete Sections E
Rev. No : 0
Date : 22.07.2013

Write off No. :

Date:

Days overdue:
Total value:
Others. Please specify __________________________________

Intangible assets
Others. Please specify.

Book value: Rp.

ers. Please specify. _________________________________________________

Others ________________________

Total Value:

ers. Please specify. _________________________________________________

Days overdue:
Total value:

ers. Please specify. _________________________________________________


Approved by:
Director "Pendamping"

MANAGEMENT COMMITTEE
Approved by:

B.O. MACOM copy

500 million and below, approval up to PC level (complete Section E)


ve Rp 500 million, approval up to MACOM level (complete Sections E and F)
approval up to PC level (complete Section E)
roval up to MACOM level (complete Sections E and F)

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