LAMPIRAN 4.

1 : FORMULIR PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK MATERIAL LANGSUNG (BAHAN BAKU)

FORMULIR 4.4.1
Penyedia Barang/Jasa : -
Alamat : -
Nama Gabungan Barang dan Jasa : -
Pengguna Barang/Jasa : -
No. Dokumen Gabungan Barang dan Jasa : -

HARGA SATUAN (US$) N I L A I (US$)

Pemasok / Satuan/ % TKDN
No. Uraian Pekerjaan Spesifikasi Jumlah Material Upah Alat Kerja/Non Upah Total TOTAL
Negara Asal Durasi DN LN Barang
DN LN DN LN DN LN DN LN US$ % KDN

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
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- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
- - - - - - -
SUB TOTAL - - - - -

IK-MPADP-T02 Rev 01-1 Feb 07

LAMPIRAN 4.2 : FORMULIR PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK PERALATAN (BARANG JADI)

Penyedia Barang/Jasa : -
Alamat : -
Nama Gabungan Barang dan Jasa : -
Pengguna Barang/Jasa : -
No. Dokumen Gabungan Barang dan Jasa : -

HARGA SATUAN (US$) N I LA

Satuan/
No. Uraian Pekerjaan Spesifikasi Pemasok / Negara Asal Jumlah Material Upah Alat Kerja/Non Upah Total
Durasi DN
DN LN DN LN DN LN DN LN

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
KOMPONEN UTAMA:
1 Steam Turbine - - -

- Package Strong Turbine, Ltd (China) 1 LS 43,907,511 - 43,907,511 -

- Marine Freight & Insurance Big Wave, Ltd (China) 1 203,105 - 203,105 -
- Inland Tranportation - - -
2 Generator - - -

- Package MG Generator (China) 1 LS 14,635,837 - 14,635,837 -

- Marine Freight & Insurance Big Wave, Ltd (China) 1 LS 601,219 - 601,219 -
- Inland Tranportation PT. Angkut Barang (TKDN 1 LS 212,923 - 212,923 -
3 Boiler - - -

- Package Best Boiler (China) 1 LS 129,170,948 - 129,170,948 -

- Marine Freight & Insurance Big Wave, Ltd (China) 1 LS 4,065,976 - 4,065,976 -
- Inland Tranportation PT. Angkut Barang (TKDN 1 LS 1,409,024 - 1,409,024 -
4 Coal & Ash Handling - - -
Coal Unloading Jetty - - -
Coal Handling - - -
Stacker - Reclaimer - - -
Coal Conveyor - - -
Dedusting Unit - - -
Metal Detector - - -
Crusher ( In Transfer Tower) - - -
Pulverizer And Coal Feed System - - -
Electrostatic Precipitator - - -
Bag House Filter - - -
Bottom Ash Handling System - - -
Fly Ash Handling System - - -
Mobile Equipments - - -
Vacuum Cleaning System - - -
Crane And Hoist - - -
- - -
4 Balance of Plant - - -
CONDENSER AND FEEDWATER HEATING PLANT - - -
- Material
- Marine Freight & Insurance
- Inland Tranportation
PLANT WATER SYSTEM - - -

DRAINAGE AND WASTE WATER TREATMENT PLANT - - -

FIRE PROTECTION SYSTEM - - -
COMPRESSED AIR SYSTEM - - -

IK-MPADP-T02 Rev 01-1 Feb 07

 CHEMICAL FEED SYSTEM - - -
LABORATORY AND INSTRUMENTS - - -
CHLORINATION SYSTEM - - -
AIR CONDITIONING AND VENTILATION - - -
ELEVATOR - - -
CRANE AND HOIST - - -
WORKSHOP AND MACHINERY EQUIPMENT - - -
MOBILE EQUIPMENT - - -
COAL HANDLING SYSTEM - - -
FUEL OIL SYSTEM - - -
ASH HANDLING SYSTEM - - -
HYDROGEN SYSTEM - - -
VACUUM SYSTEM - - -
- - -
- - -
- - -
5 Electrical - - -
- Marine Freight & Insurance Big Wave, Ltd (China) 1 LS 2,121,116 - 2,121,116 -
- Inland Tranportation PT. Angkut Barang (TKDN 1 LS 646,004 646,004 - 646,004

- Package FOB: Trend Power, Ltd (China) 1 LS 52,719,729 - 52,719,729 -

- Package Ex-Work: PT Kelistrikan Terang (TKDN 1 LS 27,643,887 18,429,258

Generator Circuit Breaker - - -
Main Step-up Transformer - - -
Unity Auxiliary Transformer - - -
Station Service Transformer - - -
Isolated Phase Bus Duct - - -
Non Segregated Phase Bus Duct - - -
6.3 KV Switchgear - - -
6.3 KV Neutral Grounding Resistors - - -
PDC Transformers - - -
400 V Switchgear - - -
LV Bus Duct - - -
400 V Motor Control Centers - - -
Medium Voltage Motors - - -
Low Voltage Motors - - -
Sand-by Diesel Generator Set - - -
DC System - - -
Station Battery Charger - - -
220 V AC UPS System - - -
Relay, Control and Matering Panels - - -
Misscellaneous Control Panels - - -
Lighting System - - -
High Voltage Cables - - -
Medium Voltage Cables - - -
Low Voltage Cables - - -
Control & Instrumentation Cables - - -
Communication System - - -
Closed Circuit Television - - -
Grounding System - - -
HV Circuit Breakers - - -
Cable trap and Conduits - - -
CT and VT - - -
Surge Arresters - - -
Structures - - -
Line Traps - - -
Clock System - - -
SCADA - - -
150/500 KV Substation and Transmission Line System - - -
- - -
6 Instrument & Control - - -
DCS System - - -
Power Plant Operation Control Desk For CR - - -
Instrument, Control Device And Local Panels - - -
Engineering Station - - -
Supervisory & Plant Management System - - -

IK-MPADP-T02 Rev 01-1 Feb 07

 Programable Logic Control (PLC) - - -
- - -
7 Civil - - -
Steam Turbin, Boiler & BOP Foundation and Structures - - -
CW Intake & Discharge Structure - - -
Central, Administration and Miscellaneous Buildings - - -
Fuel Oil Tanks and Foundations - - -
Chimney, Chimney Foundation & Structure - - -
Pipe works support & facilities, claddings, painting - - -
Coal Unloading Jetty & Trestle and other Structures - - -
- - -
KOMPONEN PENDUKUNG: - - -
1 Supported Mechanical - - -

- Fire Protection System FOB FireMan, Ltd (China) 1 LS 2,335,700 - 2,335,700 -

- Fire Protection System Ex-Work PT Api Bagus (TKDN 60%) 1 LS 2,128,677 1,419,118
- Marine Freight & Insurance
- Inland Tranportation

Laboratory And Laboratory Equipment - - -

Air Conditioning And Ventilation System - - -
Elevator - - -
Workshop And Machinery Equipments - - -
Cranes And Hoists - - -
- - -
2 Mandatory Sparepart - - -
3 Maintenance Tool & Testing Equipment - - -
4 Consumable - - -
1 Mandatory Sparepart - - -
2 Maintenance Tool & Testing Equipment - - -
3 Consumable - - -
- - -
SUB TOTAL 646,003.97

IK-MPADP-T02 Rev 01-1 Feb 07

 #REF!

PERALATAN (BARANG JADI)

FORMULIR 4.4.2

N I L A I (US$)
%
TOTAL TKDN
LN Barang
US$ % KDN

(10) (11) (12) (13)

- - - -

43,907,511 43,907,511 - -
203,105 203,105 - -
- - - -
- - - -

14,635,837 14,635,837 - -
601,219 601,219 - -
212,923 212,923 - -
- - - -

129,170,948 129,170,948 - -
4,065,976 4,065,976 - -
1,409,024 1,409,024 - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- -
- -
- -
- - - -
- -
- - - -
- - - -
- - - -

IK-MPADP-T02 Rev 01-1 Feb 07

 - - - -
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- - - -
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- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
2,121,116 2,121,116 - -
- 646,004 100.00 0.26

52,719,729 52,719,729 - -

- - - -
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- - - -
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IK-MPADP-T02 Rev 01-1 Feb 07

 - - - -
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- - - -

2,335,700 2,335,700 - -

- - - -
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- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
251,383,088.29 252,029,092.26 0.26 0.26

IK-MPADP-T02 Rev 01-1 Feb 07

LAMPIRAN 4.3 : FORMULIR PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK MANAJEMEN PROYEK DAN PEREKAYASAAN

FORMULIR 4.4.3
Penyedia Barang/Jasa : -
Alamat : -
Nama Gabungan Barang dan Jasa : -
Pengguna Barang/Jasa : -
No. Dokumen Gabungan Barang dan : -

N I L A I (US$)
Warga Satuan/ Harga Satuan Upah (US$) % TKDN
No. Uraian Pekerjaan Kualifikasi Jumlah TOTAL
Negara Durasi DN LN Jasa
DN LN US$ % KDN

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
- - - - -
1 Engineering - - - - -
- - - - -
- - - - -
<level of Supervisor up to Manager or equivalent> - - - - -
2 Procurement - - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
<level of Supervisor up to Manager or equivalent> - - - - -
3 Project Management - - - - -
- - - - -
- - - - -
- - - - -
<level of Supervisor up to Manager or equivalent> - - - - -
4 Administration & Finance - - - - -
- - - - -
- - - - -
- - - - -
- - - - -

IK-MPADP-T02 Rev 01-1 Feb 07

 - - - - -
- - - - -
<level of Supervisor up to Manager or equivalent> - - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
SUB TOTAL - - - - -

IK-MPADP-T02 Rev 01-1 Feb 07

LAMPIRAN 4.4 : FORMULIR PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK ALAT KERJA/FASILITAS KERJA

FORMULIR 4
Penyedia Barang/Jasa : -
Alamat : -
Nama Gabungan Barang dan Jasa : -
Pengguna Barang/Jasa : -
No. Dokumen Gabungan Barang dan Jasa : -

Kepemilikan Alat Kerja

Biaya N I L A I (US$)
Satuan/ Depresiasi /
No. Uraian Pekerjaan Spesifikasi / Pemasok Jumlah TOTAL
Dibuat Dimiliki
Alokasi Durasi Sewa Alat DN LN
DN (%) (US$) US$ % KDN

(1) (2) (3) (4) (5) (6) (7) (8) (9)

- - - -
- - - -
1 Engineering Software - - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
2 Engineering Hardware - - - -
- - - -
- - - -
- - - -
- - - -
3 Construction Equipment - - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -

IK-MPADP-T02 Rev 01-1 Feb 07

 - - - -
- - - -
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- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
- - - -
SUB TOTAL - - - -

IK-MPADP-T02 Rev 01-1 Feb 07

AM NEGERI UNTUK ALAT KERJA/FASILITAS KERJA

FORMULIR 4.4.4

% TKDN
Jasa

(10)
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-

IK-MPADP-T02 Rev 01-1 Feb 07

 -
-
-
-
-
-
-
-
-
-
-
-
-

IK-MPADP-T02 Rev 01-1 Feb 07

LAMPIRAN 4.5 : FORMULIR PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK KONSTRUKSI/FABRIKASI

FORMULIR 4.4.5
Penyedia Barang/Jasa : - -
Alamat : - 0
Nama Gabungan Barang dan Jasa : -
Pengguna Barang/Jasa : -
No. Dokumen Gabungan Barang dan Jasa : -

Harga Satuan Upah N I L A I (US$)

(US$) % TKDN
No. Uraian Pekerjaan Kualifikasi Warganegara Jumlah Durasi TOTAL
DN LN Jasa
DN LN US$ % KDN

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
- - - - -
1 Engineering - - - - -
- - - - -
- - - - -
- - - - -
<level of below Supervisor down to operator or equivalent> - - - - -
2 Procurement - - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
<level of below Supervisor down to operator or equivalent> - - - - -
- - - - -
3 Project Management - - - - -
- - - - -
- - - - -
- - - - -
- - - - -
<level of below Supervisor down to operator or equivalent> - - - - -
- - - - -
4 Administration & Finance - - - - -
<level of below Supervisor down to operator or equivalent> - - - - -
- - - - -
- - - - -
- - - - -

IK-MPADP-T02 Rev01-1 Feb 07

 - - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
- - - - -
SUB TOTAL - - - - -

IK-MPADP-T02 Rev01-1 Feb 07

LAMPIRAN 4.6 : FORMULIR PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI UNTUK JASA UMUM

FORMULIR 4.4
Penyedia Barang/Jasa : -
Alamat : -
Nama Gabungan Barang dan Jasa : -
Pengguna Barang/Jasa : -
No. Dokumen Gabungan Barang dan Jasa : -

HARGA SATUAN (US$) N I L A I (US$)

Negara Asal /
Satuan/
No. Uraian Pekerjaan Spesifikasi Kepemilikan / Warga Jumlah Material Upah Alat Kerja/Non Upah Total TOTAL
Durasi DN LN
Negara
DN LN DN LN DN LN DN LN US$ % KDN

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
- - - - - -
1 Jasa Instalasi/Erection/Construction - - - - - -
Jasa Instalasi/Erection untuk Steam Turbine: - - - - -
Steam Turbine, by Foreign Company Biaya LN: Generation Ele 1 LS 285,871 - 285,871 - 285,871 -
Steam Turbine, by Local Company Biaya DN: PT. Electrin 1 LS 3,931,638 3,931,638 - 3,931,638 - -
- - - - -
Jasa Instalasi/Erection untuk Generator: - - - - -
Generator, by Foreign Company Biaya LN: Just Steam Lt 1 LS 487,638 - 487,638 - 487,638 -
Generator, by Local Company Biaya DN: PT. Maju Ja 1 LS 1,696,036 188,448 1,696,036 188,448 1,696,036 188,448 1,884,484 90.00
- - - - -
Jasa Instalasi/Erection untuk Boiler: - - - - - -
Boiler, by Foreign Company - - - - - -
Boiler, by Local Company - - - - - -
- - - - -
Jasa Instalasi/Erection untuk Electrical: - - - - - -
- Total Electrical, by Local Company Biaya DN: PT. Electrin 1 LS 3,931,638 3,931,638 - 3,931,638 - 3,931,638 100.00
- Total Electrical, by Foreign Company Biaya LN: Generation Ele 1 LS 285,871 - 285,871 - 285,871 285,871 -
- - - - - -
Jasa Instalasi/Erection untuk Supported Mechanical: - - - - - -
- Fire Protection System, by Foreign Company - - - - - -
- Fire Protection System, by Local Company - - - - - -
- Laboratory and Instruments, by Foreign Company - - - - - -
- Laboratory and Instruments, by Local Company - - - - - -
- Air Conditioning and Ventilation, by Foreign Company - - - - - -
- Air Conditioning and Ventilation, by Local Company - - - - - -
- Elevator, by Foreign Company - - - - - -
- Elevator, by Local Company - - - - - -
- Crane and Hoist, by Foreign Company - - - - - -
- Crane and Hoist, by Local Company - - - - - -
- Workshop and Machinery Equipment, by Foreign Company - - - - - -
- Workshop and Machinery Equipment, by Local Company - - - - - -
- - - - - -
Jasa Instalasi/Erection untuk BOP: - - - - - -
- Condenser & feed Water Heating Plant, by Foreign Company - - - - - -
- Condenser & feed Water Heating Plant, by Local Company - - - - - -
- Plant Water System, by Foreign Company - - - - - -
- Plant Water System, by Local Company - - - - - -
- Drainage & Waste Water Treatment Plant, by Foreign Company - - - - - -
- Drainage & Waste Water Treatment Plant, by Local Company - - - - - -
- Fire Protection System, by Foreign Company - - - - - -
- Fire Protection System, by Local Company - - - - - -
- - - - - -
IK-MPADP-T02 Rev 01-1 Feb 07
 Jasa Instalasi/Erection untuk Civil Work: - - - - - -
- Steam Turbine Foundation & Structure, by Foreign Company - - - - - -
- Steam Turbine Foundation & Structure, by Local Company - - - - - -
- Boiler & Auxiliary Foundation, by Foreign Company - - - - - -
- Boiler & Auxiliary Foundation, by Local Company - - - - - -
- CW Intake & Discharge Stucture, by Foreign Company - - - - - -
- CW Intake & Discharge Stucture, by Local Company - - - - - -
- Chimney Foundation & Structure, by Foreign Company - - - - - -
- Chimney Foundation & Structure, by Local Company - - - - - -
- Coal Unloading Jetty & Acces Trestle Stuctures, by Foreign Company - - - - - -
- Coal Unloading Jetty & Acces Trestle Stuctures, by Local Company - - - - - -
- - - - - -
2 Commissioning & Test - - - - - -
- - - - - -
3 Manufacture Inspection & Design Review Expedition - - - - - -
- - - - - -
4 Project Insurance - - - - - -
- - - - - -
5 Training - - - - - -
- - - - - -
6 Other General Srvices (Building, Electricity, Water, - - - - - -
Communication/Telp, etc) - - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
- - - - - -
SUB TOTAL 9,559,311.84 1,247,829.19 6,101,993.48 156.66

IK-MPADP-T02 Rev 01-1 Feb 07

DALAM NEGERI UNTUK JASA UMUM

FORMULIR 4.4.6

%
TKDN
Jasa

(13)
-
-
-
-
64.43
-
-
-
27.79
-
-
-
-
-
-
64.43
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
IK-MPADP-T02 Rev 01-1 Feb 07
 -
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
156.66

IK-MPADP-T02 Rev 01-1 Feb 07

LAMPIRAN 4.7 : FORMULIR ISIAN DAN CONTOH PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI
UNTUK ANALISA HARGA SATUAN

FORMULIR 4.4.7
Nama Penyedia Barang/Jasa : -
Alamat : -
Nama Gabungan barang dan Jasa : -
Pemilik Gabungan barang dan Jasa : -
No. Dokumen Gabungan barang dan Jasa : -

HARGA SATUAN (US$)

Spesifikasi / Pemasok / Satuan/
No. Uraian Pekerjaan Jumlah Harga (US$) Material Upah Alat Kerja/Non Upah Total
Kualifikasi Kepemilikan Durasi
LN DN LN DN LN DN LN DN

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
LAMPIRAN 4.8 : FORMULIR REKAPITULASI PENILAIAN CAPAIAN TINGKAT KOMPONEN DALAM NEGERI
GABUNGAN BARANG DAN JASA PRODUKSI DALAM NEGERI

FORMULIR 4.4.8

Penyedia Barang/Jasa :

Alamat :

Nama Gabungan Barang dan Jasa :

Pengguna Barang/Jasa :

No. Dokumen Gabungan Barang dan Jasa :

Nilai Gabungan Barang dan Jasa*) ( US$ ) TKDN

Uraian Pekerjaan TOTAL
DN LN Barang / Jasa GABUNGAN
US$ % KDN
(1) (2) (3) (4) (5) (7) (8)
Barang

I. Material Langsung ( Bahan Baku ) - - - - - -

II. Peralatan ( Barang Jadi ) 646,004 251,383,088 252,029,092 0.26 0 0.26

A. Sub Total Barang 646,004 251,383,088 252,029,092 0.26 0 0.26

Jasa

III. Manajemen Proyek dan Perekayasaan - - - - - -

IV Alat Kerja / Fasilitas`Kerja - - - - - -

V. Konstruksi dan Fabrikasi - - - - - -

VI. Jasa Umum 9,559,312 1,247,829 6,101,993 156.66 157 3.71

B. Sub Total Jasa 9,559,312 1,247,829 6,101,993 156.66 157 3.71

C. TOTAL Biaya ( A + B ) 10,205,316 252,630,917 258,131,086 3.96 3.96

*) Nilai Gabungan Barang dan Jasa dapat diambil dari nilai job order, lelang, atau kontrak.
Capaian nilai TKDN diatas dinyatakan sendiri oleh

Formulasi Perhitungan

% TKDN Gabungan = Biaya Barang (3C) - Biaya Barang Komponen Luar Negeri (3A)
Barang dan Jasa +
Biaya Gabungan Barang dan Jasa (9C)

Biaya Jasa (8C) - Biaya Jasa Komponen Luar Negeri (8A)

Biaya Gabungan Barang dan Jasa (9C)

Jakarta, ……….. 2010

Dinyatakan Oleh,
0

……………………….
Jabatan

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