Memberikan imbalan bunga kepada:
Nama Wajib Pajak :.........................................(3) NPWP :.........................................(9) Alamat :.........................................(10) NOP :.........................................(11) Alamat Objek Pajak :........................................(12) Jenis Pajak :.........................................(13) Masa/Tahun Pajak :.........................................(14) Sejumlah :Rp.....................................(15) Terbilang :.........................................(16)
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