Booking.com B.V.

P.O. Box 1639

1000 BP Amsterdam
The Netherlands
Fax:
Phone: +62 3613008747
VAT number: NL805734958B01
Individual entrepreneur I Made Suarta Jaya Registered in the Netherlands No.:
I Made Suarta Jaya 31047344
Jalan Raya Tuka Dalung 63 www.booking.com
80351 North Kuta
Indonesia

Accommodation number: 3122558

Invoice number : 1531101717
Date: 03/10/2018
Period: 01/09/2018 - 30/09/2018

INVOICE
Description Room Sales Commission

RESERVATIONS IDR 55328604 IDR 9884021

Total amount due IDR 9884021

Payment Due: October 16, 2018

Please transfer the total amount due to our bank account below by the Payment Due date. Be sure to include INVOICE
1531101717 and ACCOMMODATION NUMBER 3122558 with your payment instructions.

PT Bank Mandiri (Persero), Tbk

Plaza Mandiri, Jl. Jend. Gatot Subroto Kav. 36-38,
Jakarta 12190
SWIFT : BMRIIDJA
SKN Clearing Code: 0080017
ACCOUNT: 8887503122558
ACCOUNT HOLDER: Booking.com B.V.
ACCOUNT CURRENCY: IDR

Payment should be made in (IDR) Indonesian Rupiah only

PLEASE BE AWARE THAT OUR INVOICES ARE BASED ON DEPARTURE DATE AND NOT ON ARRIVAL DATE

For a detailed overview of reservations please log in to your Extranet (http://www.booking.com/hotelaccess), go to

Finance tab and click on "Reservation Statements"

For finance and invoice related questions,

please visit our PARTNER HELP CENTER
Part IV INDONESIA WITHHOLDING AGENT

Tax ID Number :
Name :

Full address :
Contact Number : email :

Part V TO BE COMPLETED IF THE INCOME RECIPIENT IS AN INDIVIDUAL

1. Name of Income Recipient :
2. Date of birth (mm/dd/yyyy) : / /

3. Full address :
4. One of the principal purpose of the arrangements or transactions is to obtain Yes No
benefit under the convention and contrary to the object and purpose of the DTC
5. Are you acting as an agent or a nominee? Yes No
6. Do you have permanent home in Indonesia? Yes No
7. In what country do your ordinarily reside?

8. Have you ever been resided in Indonesia? Yes No

If so, in what period? / / to / /

Please provide the address :

9. Do you have any office, or other place of business in Indonesia? Yes No

If so, please provide the address :

Part VI TO BE COMPLETED IF THE INCOME RECIPIENT IS NON INDIVIDUAL

1. Country of registration/incorporation : The Netherlands

2. Which country does the place of management or control reside? The Netherlands

3. Address of Head Office : Herengracht 597, 1017 CE Amsterdam

4. Address of branches, offices, or other place of business in Indonesia (if any) :

n/a

5. One of the principal purpose of the arrangements or transactions is to obtain Yes v No

benefit under the convention and contrary to the object and purpose of the DTC
6. There are relevant economic motives or other valid reasons for the v Yes No
establishment of the foreign entity
7. The entity has its own management to conduct the business and v Yes No
such management has an independent discretion.
8. The entity has sufficient assets to conduct business other than the assets v Yes No
generating income from Indonesia.
9. The entity has sufficient and qualified personnel to conduct the business. v Yes No
10. The entity has business activity other than receiving dividend, interest, v Yes No
royalty sourced from Indonesia.

I declare that I have examined the information provided in this form and to the best of my knowledge and belief it is
true, correct, and complete. Official Stamp (if any)

Amsterdam , 10 / 03 / 18 Manager
Signature of the income recipient or individual Place, date (mm/dd/yy) Capacity in which acting
authorized to sign for the income recipient

This form is available and may be downloaded at this website: http:/www.pajak.go.id

DGT-1 Page 2
 TO BE COMPLETED IF THE INCOME EARNED ARE DIVIDEND, INTEREST
Part VII
OR ROYALTY

1. The entity is acting as an agent, nominee or conduit Yes No

2. The entity has controlling rights or disposal rights on the income Yes No
or the assets or rights that generate the income.
3. No more than 50 per cent of the entity's income is used to satisfy claims by Yes No
other persons.

4. The entity bear the risk on its own asset, capital, or the liability Yes No
5. The entity has contract/s which obliges the entity to transfer the income Yes No
received to resident of third country.

INCOME EARNED FROM INDONESIA IN RESPECT TO WHICH RELIEF

Part VIII
IS CLAIMED
1. Dividend, Interest, or Royalties:
a. Type of income :

b. Amount of income liable to withholding tax under Indonesian Law : IDR

c. Amount of income liable to withholding tax under DTC :

Amount : Percentage :

2. Income from rendering services (including professional):

a. Type of income : Commissions
b. Amount of income liable to withholding tax under Indonesian Law : IDR

c. Amount of income liable to withholding tax under DTC :

Amount : Percentage :

d. Period of engagement (mm/dd/yy) :

/ / to / /
/ / to / /
/ / to / /
/ / to / /

3. Other Type of Income

a. Type of income :

b. Amount of income liable to withholding tax under Indonesian Law : IDR

c. Amount of income liable to withholding tax under DTC :
Amount : Percentage :

I declare that I have examined the information provided in this form and to the best of my knowledge and belief it is
true, correct, and complete. Official Stamp (if any)

Amsterdam , 10 / 03 / 18 Manager
Signature of the income recipient or individual Place, date (mm/dd/yy) Capacity in which acting
authorized to sign for the income recipient

This form is available and may be downloaded at this website: http:/www.pajak.go.id

DGT-1 Page 3