1

Project Implementation Application Sheet

2017
Project Name

Rp.125,000,000.

Budget Amount 00 Budget Item

Project
Scope and work list

[ ] open-bidding

[ ] Invited bid

[ ] competitive negotiation
Type of Delegation
[ ] Enquiry comparison

[ ] Direct delegation

Recommended
Contractor and See Appendix Contractor Recommendation Approval Sheet
Reasons

Executing Dept

Administration
Department


Finance and
Operation Dept.

Vice Director In
Charge

President Director
 2

Recommended Contractor Approval Form
2017 05 01

Project Name

Qualification
Performance Requirement Authorized Capital Certificates or Qualification Reason for Direct Delegation
for Recommended
Contractor

1. Telah melakukan inspeksi peralatan Rp. 540.000.000,- Sertifikat perusahaan Jasa K3
sejak tahun 2010. Nasional untuk melakukan
pemeriksanaan alat
2. Telah melakukan inspeksi peralatan
PT.S pada PLTU lainnya di SUMSEL
ASE contohnya PLN Bukit asam dan PLN
Recommended S Kramasan.
Contractor


Reasons for Bid leading group

Recommended
Contractor

Sofyan

Recommended by: Dept. in charge Finance and Operation Dept.
Executing Dept.

Vice Director In Charge Vice Director of Finance Vice director in Charge of law President Director

Business Negotiation and Enquiry Form

Project Name Expense Item

Project Content

contact
Contractor name Initial Price Final Price tax Contact info
Enquiry Negotiation
Record

Enquiry Result

Attendants

Executing Dept.

Finance and
Operation Dept.

Vice Director In Charge



Vice Director of Finance

President Director

Contract Approval Form
(Title): ( ) construct ( ) service ( ) materials Date:

Contract name Contract No.

Contract
Contractor Amount

Expense Item Processed by

Brief

Contract Content

countersigned by

Finance and Operation Dept.
Executing Dept.

Security, health
ADMIN Dept. and environmental Dept.

Vice Director in charge

Vice director in charge of finance

Vice director in Charge of law

13


General Manager

Chairman

:1.

Performance Evaluation Form on Contract

Contract Name

Date
Processed by

No. Evaluation Items Evaluation Standards Amount Rating

Countersigned by

Executing Dept.


Dept. in Charge

Finance and Operation Dept.

Chief Engineer

Vice Director in charge

President Director

<1

>1

Contract Modification or Termination Form
(Title): ( ) construct ( ) service ( ) materials Date:

Contract Name: Contract No.

Revised Time
Contract Company
(with this time)

Original Contract This revised AMT

AMT(of Tax)

Accumulative revised
AMT

Revised Contract
Processed By
AMT(of Tax)

Revised Gist

countersigned by

Executing Dept.: Finance and Operation Dept.

Security, health and environmental Dept.:
ADMIN Dept.:

Vice Director in Charge

Vice Director of Finance

Vice Director of Law

General Manager

Chairman


Direct Delegation Application form

Date:

Project Name

Dept in Charge Delegated company

Expense Item Budget

Content

Reason for Direct

Delegation

Technical Standards

Estimated Project
Period

Processed by
ADMIN Dept.: Finance and Operation
 Executing Dept: Dept.

Vice Director In
Charge

Direct Delegation acceptance certificate

Project Name Dept.

Delegated company Time

Opinion on Acceptance


Signature

Chief Engineer

Vice Director In Charge

Direct Delegation Settlement Form

Project Name: Delegated Company

Settlement Budget

Project profile


Countersigned by

Executing Dept. :

Operation and Finance Dept. :

Chief Engineer

Vice director in Charge

Vice director of Finance

President Director

9
Contract Payment Approval Form
Date: (Currency) RP( ) USD( ) RMB( )

Contract Name :

Contract Num : Payment series

Contr. AMT(incl. Tax) Accumulative Revised Amt Revised Contr. AMT(incl. VAT of Contr. AMT
tax)
WHT Rate WHT of Contr. AMT Total AMT Payable to Sp Contract Quality Guarantee
:

Project Progress Deducting Prepayment Other Deducting Items Deducting Guarantee this time

Receiving Invoice AMT

Included VAT of Invoice

Included WHT of Invoice

Paying AMT to Supplier

Accumulative progress(with this Payment pattern Pmt Times(within this)

Budget classification
time) ()

Account Bank
Account Name Account No. Processed by

Executing Dept:

Contract Supervisor

Dept of Finance &Operation

Chief Engineer

Vice Director in Charge



Vice Director of Finance

President Director

:10

Project Completion Acceptance Form

Project Name Contract No.

Contractor Contract price

Start Time Completion Time

Acceptance
Item

Item Evaluation Check and Ratify

Acceptance

Result

Project Quality Evaluation



Technical Evaluation

Contractor

Acceptance Members

Chief Engineer

Vice Director in Charge

 11

Quality Guarantee Release Form

Contract
Contract Name
Number

Contractor Start Date

Total Contract
Complete Date
Amount

Quality Guarantee Guarantee

Amount Date

Quality Guarantee Examination items Examination Result

Quality Guarantee
Examination
Resolution

Executing Dept

Dept. in Charge

Finance
and Operation Dept.


Chief Engineer

Vice
Director In Charge

Vice
Director of Finance

President
Director
 12

Contract Settlement Approval Form

Date

Project
Contractor

Contract

Amount Contract No.

Settlement Budget

Project profile

XXXX

XX XX.

Executing Dept

Finance and Operation

Dept.

Chief Engineer

Vice Director In Charge

21


Vice Director of
Finance

President Director