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ANNEXURE I

Jakarta, ………………… , 2022

Dear

We inform you that we have received your (……………………….) VAS/Visa fee with details
below: Name : hue lou gnean Murielle ……………………………………
Visa Category : tourist………………………..............
Amount : IDR ……911,100.00………………………...

The refund will be reduced by Rp. 2,900.00 in accordance with the provisions of out bank
transfer fee. As per your approval, here is your bank account as per below:

Name of Account : ………hue lou gnean Murielle………........................


Account Number : ………5260833504………........................
Name of Bank : ……bca …………........................
Bank Branches : ………………... Jakarta...

We will process your refund fee within 14 working days after we received your approval and
bank details data.
Within 7 days after we inform you about this, and we have not yet receive any confirmation of
approval and data bank details, then the excess charge is non-refundable.

Thank you. Approved by:hue Lou


gnean Murielle

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