STATEMENT LETTER

To Whom It May Concern

I……….., holding Korean passport number ………….. hereby solemnly and sincerely declare that I am
willing:

1. to voluntarily undergo quarantine and or treatment at its own expense in quarantine facility or
health care facilites designated by Indonesia government if the PCR test result are positive or
show the COVID-19 clinical symptoms upon arrival in Indonesia as regulated by Minister of Law
and Human Right’s Regulation 26/2020.
2. willing to do health monitoring during the quarantine or isolation period in accordance with
health protocols and statutory provisions;

I understand this is a legal obligation and failure to comply will be resulted in denial to enter Indonesia’s
territory

Best Regards
Jakarta, 23 August 2021

Materai 10.000

……………….