Page 1

FIN-001-TERM OF REFERENCE (TOR) & BUDGET APPROVAL

(To be filled by requester)

Activity
Activity name (Based on Work Plan) Budget in Workplan Budget Remain Budget requested
code
01-10.1.1.1- Supervision- supervision to Provinces/District, 16
district, , ,, 3 days, 1 person out town, 2 time a year

01-10.1.1.1- Supervision- supervision to Provinces/District, 16

district, , ,, 3 days, 1 person out town, 2 time a year

Detail Activity

IWiFi TB implementation at North Sumatera, 25 - 30 Juni 2018

Prepared by Direct SPV Approval / PMC Review Finance Review

Technical Review
Date : Date : Date : Date :
______________ ______________ ______________ ______________

AAM APLICABLE AAM APLICABLE

Name : Name : Name : Name :

Final Approval
Date :

____________________________________

AAM APLICABLE

Name :
TC/PC/DTS/DOPS/CR

FINANCIAL CLEARANCE
Financial
Date Requested TOR Number Location Code Project Code Note
Year
2016 4-Apr-16 01 - RO
 Page 2

FIN-002-TOR Budget Request

WiFi TB implementation at North Sumatera, 25 - 30 Juni 2018

QTY /
Volume Paid Via Admin
NO Cost Item Budget Unit Cost Perso Total Paid to Requester
/ Day Office
n
-

Perdiem Sumut 6 6,660,000 6,660,000

370,000 3
Airport Transport Jakarta - Sumut 2 2,670,000 2,670,000
445,000 3
land transport 2 1,020,000 1,020,000
170,000 3
Accomodation 5 13,500,000 13,500,000
900,000 3
Flight Ticket 2 24,000,000 24,000,000
4,000,000 3
- -
-
-
-

TOTAL 47,850,000 37,500,000 10,350,000

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TOR Number : Location Code : Advance Activity Clearance for Pervious Advance
Advance Number : 01 Travel advance Previous Advance Balance :
Project Code : 3.ID.101.4 - CTB APA 4
Cash Advance
Name of Staff : Harmi Prasetyo Eligible for Advance Request
Budget : Advance Request
Volu
Activity Name, Budget me /
No Date , Place and Cost Item Code Unit Cost Day QTY / Person Total % Amount
- 0% -
WiFi TB implementation at Sumut, - -
25-30 June 2018 - -
Perdiem Sumut 370,000 6 3 6,660,000 70% 4,662,000
Airport Transport Jakarta - Sumut 445,000 2 3 2,670,000 100% 2,670,000
land transport 170,000 2 3 1,020,000 100% 1,020,000
Accomodation 900,000 5 3 13,500,000 0% -
Flight Ticket 4,000,000 2 3 24,000,000 -
0 - -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
Total Budget Estimation 47,850,000
Total Advance Request 8,352,000
Total Advance Reviewed by Finance
Travel Information
Route 1 Co - Travel Budget Code
Date : 1
From………… To………… Time : 2
Date : 3
From………… To………… Time : 4
Please pay the amount indicated above to Other Information:
Indicate Form of Payment : ( ) Check ( ) Wire Transfer* ( ) Cash
*If wire payment is requested, the following information is required, where applicable :
Bank Name : Account Number :
Bank Address : Name on Account :
Bank Route No. :
By signing this form, I comply to the KNCV Finance and Travel Date Requested Please Attached Document :
regulation and will send the expense report for this advance 1. TOR
Max.30 day after the advance received. 2. Invitation letter
0 3. Other request document
Approved By Direct Proces by :
PMC Review Finance Review Final Approval
Supervisor

AAM is Applicable AAM is Applicable AAM is Applicable

Name : Name : Name : Name :

PROJECT CODE
TOR Number Prepared by : Location Code :
Advance Number

01
Date of Submission
Reporting Periode Name of Staff FIN-004-EXPENSE REPORT
LUMPSUM TRANSPORT
NO Activity Name, BUDGET TOTAL TOTAL EXPERT TOTAL TICKET AIRPORT LAND TRANSPORT TRANSPORT ACCOMODATION
TOTAL AMOUNT
Date , Place and Cost Item CODE MEAL AND OTHER COST
PERDIEM FEE LUMPSUM RETURN TRANSFER TRANSPORT LOCAL TOTAL
ALOWANCE
WiFi TB version 2 implementation at East Java Provinces - - -
13-17 May 2018 - - -
- - -
Tiar Salman 1,476,000 1,476,000 426,000 426,000 1,902,000
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
- - -
1,476,000 426,000 -
TOTAL 1,902,000

Total Amount
TOTAL LUMPSUM AND TRANSPORT EXPENSES 1,902,000

TOTAL ACCOMMODATION AND OTHER EXPENDITURES -

TOTAL EXPENSES 1,902,000

ADVANCE INSTALMENT -

TOTAL REFUND/TO BE PAID 1,902,000

Please pay the amount indicated above to Indicate Form of Payment : Direct Supervisor Approval PMC Review Finance Check Finance Review Approved by
*If wire payment is requested, the following information is required, where applicable :
Bank Name : Account Number : Check
Bank Address : Wire Transfer AAM is Applicable AAM is Applicable AAM is Applicable AAM is Applicable
Bank Route No.: Name on Account : Cash
PMC

Process by : Name : Name : Name : Name : Name :

 FIN-005-EXPENSE REPORT CHECKLIST
PROJECT CODE : 3.ID.102.3 - CTB APA 3 B
TOR NUMBER :
ADVANCE NUMBER :
DATE OF SUBMISSION :
REPORTING PERIODE :
COST CENTER / LOCATION CODE : 03-KNCV Central Java

CONDITION DATE SHOULD BE

NO TYPE OF DOCUMENT A / NA REMARK
COMPLETE NOT COMPLETE OF COMPLETED COMPLETED ON
1 EXPENSE REPORT FILL IN PROPERLY

2 ASIGMENT LETTER

3 INVITATION LETTER

4 PERDIEM CALCULATION

5 PERDIEM RECEIPT

6 TICKET

7 BORDING PASS

8 INVOICE

9 ATTENDACE LIST
DETAIL ROOM LIST (ONLY APPLICABLE FOR
10 WORKSHOP)

11 SUMMARY ACTIVITY REPORT

12 OTHER RECIPT (PLEASE STATED)

Meals Receipt

Snack Receipt

3..........................................................

4..........................................................

5..........................................................

Note :
PA/PPA should reconsiling with FINANCE all pending document each week until supporting document completed

SUBMITTED BY RECEIVED BY

Name Name
Date Date
PA/PPA/REQUESTER Finance
FIN-006-PAYMENT REQUEST
KNCV INDONESIA

TOR Number : Location Code :

Purchase Request Number: 01-KNCV RO
Project Code :
Date :
Paid to :
(To be filled by requester)
No Description Amount Budget Line
1 Overbooked Balance Challenge TB Bank Account from ANZ 114,188,075 0.0.4.13
to UOB
Bank charges (5,000)
Closing account fee 6 accounts (600,000)

Total payment requested 113,583,075

Please pay the amount indicated above to Rp 113,583,075

To be filled by Finance Department :
Indicate Form of Payment : ( ) Check ( X ) Wire Transfer* ( ) Cash
*If wire payment is requested, the following information is required, where applicable :
Bank Name UOB Account Number : 632-300-242-5
Bank Address KCP TEBET Name on Account : KNCV CHALLENGE TB
Bank Route No.

Document Checking
No. Document Name Completed not completed need submitted
1.
2.
3.
4
Please attached supporting document

Name of Requester : Approved by Direct Supervisor

Date Date
Name Swastuti H Name Nico H
Position FA Position FM

Signature Signature

Finance Review Processed by

Date Date
Name Hendra S Name
Position HFA Position

Signature Signature

Approval by Authorized Person as in AAM

Date
Name
Position

Signature
 FIN-007-RECEIPT AND PERDIEM CALCULATION

KNCV TUBERCULOSIS FOUNDATION

Name Tiar s Activity Name : WIFI TB Implementation

Position STO DM Place and Date : Surabaya and Tulungagung, 13-17 May 2017
PER DIEM CALCULATION

Breakfast Lunch Dinner Other Cost Claimed Per

Travel Start Travel End Standart Diem
Date Activity Condition
(24 Hour) (24 Hours) Rate 10% 20% 30% 40%

13-May-18 Keberangkatan 15.00 5 410,000 0 0 123,000 164,000 287,000

14-May-18 Day 2 2 410,000 0 82,000 123,000 164,000 369,000

15-May-18 Day 3 4 410,000 0 0 123,000 164,000 287,000

16-May-18 Day 4 4 410,000 0 0 123,000 164,000 287,000

Day 5 - 0

Day 6 - 0

knvb - 0

Day 8 - 0

Day 9 - 0

17-May-18 Kepulangan 15.00 2 410,000 0 82,000 0 164,000 246,000

Total Perdiem Claim 1,476,000

* Perjalanan dimulai sebelum jam 7 pagi, breakfast dapat di klaim (prepared by)
* Perjalanan dimulai sesudah jam 15.00, lunch tidak dapat di kalim
* Ketibaan kembali sesudah jam 19.00 malam, dinner dapat di klaim
* Per Diem eligible untuk perjalanan diluar duty station dan menginap
* Perjalanan diluar duty station tidak menginap dan lebih dari 8 jam dapat mengajukan
klaim meal Allowance sebesar IDR 125,000,-
* Masukan kondisi "1" bila Breakfast,Lunch,Diner disediakan dalam kegiatan
* Masukan kondisi "2" bila Breakfast disediakan dalam kegiatan
* Masukan kondisi "3" bila Diner disediakan dalam kegiatan
* Masukan kondisi "4" bila Breakfast and Lunch disediakan dalam kegiatan (Name dan tandatangan)
* Masukan kondisi "5" bila semua tidak disediakan dalam kegiatan
* Masukan kondisi "6" bila Lunch tidak disediakan dalam kegiatan
* Masukan kondisi "0" bila semua disediakan dalam kegiatan

RECEIPT/KWITANSI
Sudah terima dari KNCV Tuberculosis Foundation
Banyaknya Uang

Untuk pembayaran

Unit Kuantiti Unit Cost

Perdiem = 1,476,000
Ticket X X = 0
Expert Fee kegiatan X X = 0

Airport Transport 1 travel X 2 X 213,000 = 426,000

Local Transport travel X X = 0

Land Transport travel X X = 0
= 0
Total 1,902,000

Advance Rp.
Jumlah diterima Rp.
Penerima

Note : Kwitansi hanya berlaku untuk pembayan pada pihak ke-3 Nama : Tiar s
Jabatan :
 Nico Hardianto: Nico Hardian
FIN-008-RECEIPT AND PERDIEM CALCULATION
Please fill in DSA rate of Please fill in %
your travel your travel
Name Activity Name :

Position Place and Date :

PER DIEM CALCULATION

Breakfast Lunch Dinner Other Cost Claimed Per

Travel Start Travel End % DSA Eligible DSA Diem
Date Activity Condition DSA Rate
(24 Hour) (24 Hours) Rate Rate 10% 20% 35% 35%

12-May-15 Keberangkatan 12.00 5 160 39% 62 0 12 22 22 56

Jakarta 2 160 39% 62 0 12 22 22 56

Surabaya 2 160 40% 64 0 13 22 22 58

Day 4 0 0 0% - - 0

Day 5 0 0 0% - - 0

Day 6 0 0 0% - - 0

Day 7 0 0 0% - - 0

Day 8 0 0 0% - - 0

Day 9 0 0 0% - - 0

Day 10 0 0 0% - - 0

Day 11 0 0 0% - - 0

Day 12 0 0 0% - - 0

Day 13 0 0 0% - - 0

Day 14 0 0 0% - - 0

Kepulangan 17.00 5 4,698,135 35% 1,644,347 164,435 328,869 0 575,522 1,068,826

Total Perdiem Claim 1,068,996

* Perjalanan dimulai sebelum jam 7 pagi, breakfast dapat di klaim (prepared by)
* Perjalanan dimulai sesudah jam 15.00, lunch tidak dapat di kalim
* Ketibaan kembali sesudah jam 19.00 malam, dinner dapat di klaim
* Per Diem eligible untuk perjalanan diluar duty station dan menginap
* Perjalanan diluar duty station tidak menginap dan lebih dari 8 jam dapat mengajukan
klaim meal Allowance sebesar IDR 125,000,-
* Masukan kondisi "1" bila Breakfast,Lunch,Diner disediakan dalam kegiatan
* Masukan kondisi "2" bila Breakfast disediakan dalam kegiatan
* Masukan kondisi "3" bila Diner disediakan dalam kegiatan
* Masukan kondisi "4" bila Breakfast and Lunch disediakan dalam kegiatan (Name dan tandatangan)
* Masukan kondisi "5" bila semua tidak disediakan dalam kegiatan

RECEIPT/KWITANSI
Sudah terima dari KNCV Tuberculosis Foundation
Banyaknya Uang

Untuk pembayaran

Kuantiti Unit Cost

Perdiem = 1,068,996
Ticket X X = 0
Expert Fee X 2X = 0

Airport Transport X 1X = 0

Local Transport X 4X = 0
Land Transport X X = 0
= 0
Total 1,068,996

Advance Rp.
Jumlah diterima Rp.
Penerima

Note : Kwitansi hanya berlaku untuk pembayan pada pihak ke-3 Nama :
Jabatan :
 FIN-010-Travel / Other Expenses Declaration Form
(Only for amounts under IDR250,000)

Date :

Employee Name :

Title :

Expense amount being declared :

I hereby declare that :

1 The above expense for _______________________________________________________________

2 During my approved travel or activity ______________________________________________________________

3 The vendor / provider was unable to provide an official receipt / I lost the receipt

Declared by Payment Approved by line manager:

(Employee name's and signature) (Full Name and signature)

Note: This form can ONLY be used in exceptional circumstances where an official / original receipt is not available.

FIN-010-Travel / Other Expenses Declaration Form

(Only for amounts under IDR250,000)

Date :

Employee Name :

Title :

Expense amount being declared :

I hereby declare that :

1 The above expense for _______________________________________________________________

2 During my approved travel or activity ______________________________________________________________

3 The vendor / provider was unable to provide an official receipt / I lost the receipt

Declared by Payment Approved by line manager:

(Employee name's and signature) (Full Name and signature)

Note: This form can ONLY be used in exceptional circumstances where an official / original receipt is not available.

FIN-010-Travel / Other Expenses Declaration Form

(Only for amounts under IDR250,000)

Date :
Employee Name :

Title :

Expense amount being declared :

I hereby declare that :

1 The above expense for _______________________________________________________________

2 During my approved travel or activity ______________________________________________________________

3 The vendor / provider was unable to provide an official receipt / I lost the receipt

Declared by Payment Approved by line manager:

(Employee name's and signature) (Full Name and signature)

Note: This form can ONLY be used in exceptional circumstances where an official / original receipt is not available.