MINISTRY OF FINANCE OF THE REPUBLIC OF INDONESIA DIRECTORATE GENERAL OF TREASURY DIRECTORATE OF STATE CASH MANAGEMENT Pred: Praptosuharo I uidng 4 Floor Jalan Lapangan Sorte Tirut No. 24 Jakarta 10710 Phone (6221) 848289 (20 LINE) PSV S400 540, Fx (a2 1) 3624546, No. S- 36 /PB.34/2021 May 06 , 2021 Ms. Anna McNicol Counsellor, Infrastructure and Economic Governance Department of Foreign Affairs and Trade (DFAT) Australian Embassy Jakarta Ji, Patra Kuningan Raya. 1-4 Jakarta Selatan 12950 Subject: Application for Withdrawal of AusAid Grant No. 73826 Dear Ms. Anna McNicol, Pursuant to the Direct Funding Agreement No.73826 between the Government of Australia and the Government of Indonesia dated September 11, 2017, we hereby kindly request for withdrawal to the designated account of Grant for Palembang City Sewerage Project (PCSP) amounting to AUD2,000,000. (sixth tranche payment). We acknowledge that the Australian Government is intended to cover the transfer fee of AUDSO however it will be treated as excluded from the withdrawal. The designated account of the Grant mentioned is shown as follows’ - Name of Account Reksus Kemenkeu untuk Kegiatan Palembang City Sewerage Project (PCSP) No. 73826 Dalam Valuta AUD - Account Number 602009311980 - Name and address of : Bank Indonesia the beneficiary's bank JI. MH. Thamrin No.2 Jakarta, 10110, Indonesia - Name and address of : Directorate General of Treasury, MoF the beneficiary Jl Lapangan Banteng Timur No.2-4 Jakarta Pusat 10710 Indonesia Please provide us a notice of disbursement after the fund has been transferred. Thank you for your kind cooperation Yours sincerely, Ce: 1. Director General of Fiscal Balance, Ministry of Finance; 2. Banking Services, License, and Treasury Operation Department, Bank Indonesia; 3. Director Evaluation, Accounting and Settlement, D.G. of Debt Management.Aue nao sacra gy ee APPLICATION FOR WITHDRAWAL Instructions: You ean us is form to request a payment anor document expenses. Pleste complete and son tis form, an een wih any requires attachments te AusAID. al he adress fund inthe csbursemert et Fo” general enguites lease sand on emai te [nsot ema edares| Karsiaan Auswalla indonesia eS ‘A. Application type and project reference Application type 2. Financing number 3. Advance to designates account 602008311980, No73026 (oame or ruber of éesgnats accoun AL Advance to designated account il secons A, B,D) 2. Borrower reference “Avance to and docureriaton of deberatd accoué tal secon) = Documentaton a pir aavance() to docanated acount ( eacbons A.C, O) 006173826/2018 b.__ Reimbursement (ial sections) lect payment «at sections) (onetcian’s paymantinvlce reference 5. Payment instructions 43, Application currency 4b. Application amount 4c, Equivalent payment currency ferent fram apleatoncureney) Australian Dollar 2,000,000 44. Application amount (i words) Two Million Australian Dollar 5. Namo and address of beneficiary 5. Amount tobe paid in instalments? Yas No_i_ Ministry of Finance of the Republic of Indonesia (yen complete Fam 1061 "Requested Schedule or Advance Panos) Directorate Goneral of Treasury, JI. Lapangan Banteng Timur 2-4 Jakarta 7a, Name and address ofthe beneficiary's Danie Tb, Account no. oftho beneficiary Te, SWIFT code ofthe beneficiary's bane ‘Bank indonesia, JIM.H. Thamrin No.2 Hein eepeieeee ans INDOIDJA ‘Glee 502009311980 42, Namo and address ofthe Intermediary bank 8b, Account no. ofthe beneficiary 8. SWIFT code ofthe intermediary bank tthe Intermediary bonk Reserve Bank of Australia Sydne RSBKAUZS yaar 816208 8. Special payment instructions (any) C. Documentation of eligible expenses 10. Documentation type(s) ‘1. LoanGrant Category and contract reference expanses rele fo more than oe etm inane report ne loanigant etapa: cara: eerense, eave 114 sha 178 Bank and ensure = Satementor eceraaure Infomaton neudedn he surporing cocursetaton S Cepies a recs (eg. nvices, receipts) ‘Ma. LoansGrant Category reference ‘Hb. Contact reference 120. Documentation eureney ‘2b. Documented amount ‘26. Documented amount (nerds) D. Assertions and signature ‘The undersigned cores, warais and unserakes the lowing: [A Ifthe undersigned is making a request fo an advance to be dapostedn dsignated acount: (1) he amount requested e conden wih the planes project cexseneosfurtahed to AusAID. and (2) the docurertaton farts asvance ful te fishes to AURAID in accordance sith he rparing period spread ne "eet legal agreements) o debareeman letra this projec. re undereigned ie documenting oxpendes als ram a Seslanates account () he exocnses {oie by he appicaton are eile for faanelng aut the proceeds othe losntgan{n accordance wth tare te elated lage agrees. ond) tnese expenses nave rot veenfranced previusy fom sours eter than te Repub of Inconela no Wil fe underaghed enue! naing forthe wxrenses from any eter source nthe ure 8. lhe undersigned mokng a vequest fox reimbursement o rect payment) the expenses covered by he apptcaton ae ede for anc ou of the rocteds fh oarvgrant naccorsance te terme ofthe rele oval ag/eomant) and (2) these expenaas have ne ben nance prev on ‘Scrces che than the Repco indonesia or wl the undersigned request fnancng for he ecpenaes Hom any oe sour ne Me, (The undrsianed wil rake a records related tthe expenses covered his Wiha Aptcaensvalale for eviowby autos and by AUSAO stat 18. By (ame of borrower) 14. Date stoned Directorate Gonoral of Treasury may 6, 2021 18a, Print namo) and tie(s of authorised signatory Signatures) Edy Sutriono ! Deputy Director of Gash Management 18. Contact detalle Name Prone Facsinle Enat Edy Sutriono +62-21-3460230 +62-21-3844423__edy-sutriono@kemenkeu.go.id