Electronic Licensing, Approval, and Reporting Applications for Information Technology-Based Crowdfunding Service Providers

To:
The Board of Directors of Information Technology-Based Crowdfunding Service Providers, In your office.

COPY
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 21 /SEOJK.05/2022 CONCERNING ELECTRONIC LICENSING APPLICATIONS, APPROVAL APPLICATIONS, AND REPORTING FOR INFORMATION TECHNOLOGY-BASED CROWDFUNDING SERVICE PROVIDERS

In relation to the mandate of Article 9 paragraph (9) and regulations regarding electronic licensing applications, approval applications, and reporting in Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services (State Gazette of the Republic of Indonesia Year 2022 Number 2/OJK, Supplement to the State Gazette of the Republic of Indonesia Number 2/OJK), it is necessary to further regulate the procedures and mechanisms for electronic business licensing, approvals, and reporting for information technology-based crowdfunding service providers in this Financial Services Authority Circular Letter as follows:

I. GENERAL PROVISIONS
In this Financial Services Authority Circular Letter, the following terms are defined:

1. Information Technology-Based Crowdfunding Services, hereinafter abbreviated as LPBBTI, are the provision of financial services to match fund providers with fund recipients to conduct conventional financing or financing based on Sharia principles directly through an electronic system using the internet.

2. Sharia Principles are Islamic legal provisions based on fatwas and/or Sharia compliance statements from the National Sharia Council of the Indonesian Ulema Council.

3. Electronic System is a series of electronic devices and procedures that function to prepare, collect, process, analyze, store, display, announce, send, and/or disseminate electronic information in the field of financial services.

4. Information Technology is a technique to collect, prepare, store, process, announce, analyze, and/or disseminate information in the field of financial services.

5. LPBBTI Provider, hereinafter referred to as the Provider, is an Indonesian legal entity that provides, manages, and operates LPBBTI either conventionally or based on Sharia Principles.

6. Board of Directors is the company organ authorized and fully responsible for the management of the company for the interests of the company, in accordance with the company's purpose and objectives, and represents the company, both inside and outside of court, in accordance with the provisions of the Articles of Association.

7. Board of Commissioners is the company organ tasked with conducting general and/or specific supervision in accordance with the Articles of Association and providing advice to the Board of Directors.

8. Sharia Supervisory Board, hereinafter abbreviated as DPS, is a board that has the task and function of supervision and provides advice to the Board of Directors regarding the implementation of the Provider's activities to ensure compliance with Sharia Principles.

9. Merger is a legal act performed by 1 (one) or more Providers to merge with an existing Provider, resulting in the assets, liabilities, and equity of the merging Provider transferring by law to the receiving Provider, and subsequently the legal entity status of the merging Provider ends by law.

10. Consolidation is a legal act performed by 2 (two) or more Providers to consolidate themselves by establishing 1 (one) new Provider, which by law acquires the assets, liabilities, and equity of the consolidating Providers, and the legal entity status of the consolidating Providers ends by law.

11. General Meeting of Shareholders, hereinafter abbreviated as GMS, is the company organ that has authority not given to the Board of Directors or Board of Commissioners within the limits determined by laws regulating limited liability companies and/or the Articles of Association.

II. SCOPE OF ELECTRONIC LICENSING APPLICATIONS, APPROVAL APPLICATIONS, AND REPORTING

1. Licensing applications, approval applications, and reporting as mandated in Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services, submitted to the Financial Services Authority, are grouped as follows:
   a. licensing applications; b. approval applications; and
   c. reporting.

2. Licensing applications as referred to in item 1 letter a are business licensing applications for the Provider.

3. Approval applications as referred to in item 1 letter b include:
   a. approval applications for conversion from conventional Providers to Providers based on Sharia Principles; b. approval applications for changes in ownership;
   c. approval applications for increases in paid-up capital;
   d. approval applications for changes in members of the Board of Directors, members of the Board of Commissioners, and/or members of the DPS; e. approval applications for Merger or Consolidation; f. approval applications for plans to return business licenses; g. approval applications for liquidation team members; and h. approval applications for extension of the liquidation implementation period.

4. Reporting as referred to in item 1 letter c includes:
   a. reporting on the determination of controlling shareholders and changes thereto; b. reporting on the implementation of GMS approving conversion to Providers based on Sharia Principles;
   c. reporting on the use of foreign workers;
   d. reporting on the implementation of education and training programs; e. reporting on cooperation; f. reporting on data exchange cooperation; g. reporting on the opening of offices other than the head office; h. reporting on the cessation or closure of offices other than the head office;
   i. reporting on the realization of changes in the Provider's name and/or Electronic System;
   j. reporting on changes in the address of the head office and offices other than the head office; k. reporting on changes in business models;
   l. reporting on the realization of increases in paid-up capital;
   m. reporting on the implementation of GMS approving changes in ownership; n. reporting on the implementation of GMS approving Merger or Consolidation; o. reporting on the implementation of changes in ownership; p. reporting on the implementation of Merger or Consolidation; q. reporting on the implementation of settlement of rights and obligations; r. reporting on the realization of the work plan and budget for liquidation implementation; and s. reporting on bankruptcy processes.

III. PROCEDURES FOR SUBMISSION AND REQUIREMENTS FOR ELECTRONIC LICENSING APPLICATIONS, APPROVAL APPLICATIONS, AND REPORTING

1. Providers must submit licensing applications, approval applications, and reporting to the Financial Services Authority in accordance with the format contained in the Appendix of Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services, accompanied by supporting documents as required.

2. The submission of licensing applications, approval applications, and reporting as referred to in item 1 is accompanied by a self-assessment form signed by the Provider's Board of Directors as contained in the Appendix which is an integral part of this Financial Services Authority Circular Letter.

3. Licensing applications, approval applications, and reporting as referred to in item 2 are submitted to the Financial Services Authority online through the Financial Services Authority's data communication network system.

4. Supporting documents required as attachments for licensing applications, approval applications, and reporting submitted online are electronic documents that can be in the form of color scans of the original documents.

5. In the event that the Financial Services Authority's data communication network system as referred to in item 3 is not yet available or experiences technical disturbances, the submission of licensing applications, approval applications, and reporting is submitted in the form of electronic documents via email designated by the Financial Services Authority.

6. In the event of technical disturbances as referred to in item 5, the Financial Services Authority announces this on the Financial Services Authority website or via email to the Provider.

7. The submission of licensing applications, approval applications, and reporting as referred to in item 5 is submitted in the form of electronic documents that can be in the form of color scans of the original documents.

8. The submission of licensing applications, approval applications, and reporting in the form of electronic documents as referred to in item 5 is accompanied by a cover letter signed by the Provider's Board of Directors.

9. Providers must declare that the documents submitted online or via email are true and identical to the original documents.

10. The submission of licensing applications, approval applications, and reporting in the form of electronic documents as referred to in item 5 is submitted via the address mailingroomwismul@ojk.go.id or other addresses designated by the Financial Services Authority and addressed to:
    Executive Head of Insurance, Pension Funds, Financing Institutions, and Other Financial Service Institutions attn. Director of Regulation, Licensing, and Supervision of Financial Technology Wisma Mulia 2 Building, 15th Floor Jalan Jenderal Gatot Subroto Kav. 42 Jakarta 12710

11. In the event of changes to the address of the Financial Services Authority for the submission of licensing applications, approval applications, and reporting as referred to in item 10, the Financial Services Authority provides notification regarding the address change via letter or announcement.

12. Providers are deemed to have submitted licensing applications, approval applications, and reporting with the following conditions:
    a. for online submission through the Financial Services Authority's data communication network system, evidenced by a receipt from the Financial Services Authority's data communication network system; or b. for submission in the form of electronic documents via email, evidenced by a receipt from the Financial Services Authority's email.

IV. DATA STORAGE

1. Providers must store the original documents of licensing and approval documents that have been submitted through the Financial Services Authority's data communication network system or via email to the Financial Services Authority for as long as such licensing and approvals remain valid.

2. Providers must store the original documents of reporting documents that have been submitted through the Financial Services Authority's data communication network system or via email to the Financial Services Authority for a minimum period of 5 (five) years from the date of reporting.

3. The Financial Services Authority may conduct verification and/or validation of the truthfulness and reasonableness of the original documents of licensing applications, approval applications, and reporting submitted by Providers through the Financial Services Authority's data communication network system or via email to the Financial Services Authority.

4. Providers must provide the original documents of licensing applications, approval applications, and reporting as referred to in item 3 that have been submitted through the Financial Services Authority's data communication network system or via email to the Financial Services Authority during the implementation of verification and/or validation by the Financial Services Authority.

V. TRANSITIONAL PROVISIONS

Licensing applications, approval applications, and reporting that have been submitted to the Financial Services Authority in the form of electronic documents via email before this Financial Services Authority Circular Letter takes effect and have not yet received licenses, approvals, and/or reporting registration letters from the Financial Services Authority do not need to be resubmitted online through the Financial Services Authority's data communication network system.

VI. CLOSING

The provisions in this Financial Services Authority Circular Letter take effect on the date of establishment.

This copy is identical to the original
Legal Director 1
Legal Department signed
Mufli Asmawidjaja

Established in Jakarta on 25 November 2022

EXECUTIVE HEAD OF INSURANCE,
PENSION FUNDS,
FINANCING INSTITUTIONS, AND
OTHER FINANCIAL SERVICE INSTITUTIONS
FINANCIAL SERVICES AUTHORITY
REPUBLIC OF INDONESIA, sign
OGI PRASTOMIYONO

APPENDIX
CIRCULAR LETTER OF THE FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA NUMBER 21 /SEOJK.O5/2022 CONCERNING ELECTRONIC LICENSING APPLICATIONS, APPROVAL APPLICATIONS, AND REPORTING FOR INFORMATION TECHNOLOGY-BASED CROWDFUNDING SERVICE PROVIDERS

APPENDIX TABLE OF CONTENTS
PART A: LICENSING APPLICATION CATEGORIES
No. Description Application Page

1. Self-Assessment Form 1
   Provider's Business Licensing Application 4

PART B: APPROVAL APPLICATION CATEGORIES
No. Description Application Page
2. Self-Assessment Form 2
Approval application for conversion from conventional Provider to Provider based on Sharia Principles
3. Self-Assessment Form 3
Approval application for change of ownership
4. Self-Assessment Form 4
Approval application for increase in paid-up capital
5. Self-Assessment Form 5
Approval application for change of members of the Board of Directors, members of the Board of Commissioners, and/or members of the DPS
6. Self-Assessment Form 6
Approval application for Merger or Consolidation
7. Self-Assessment Form 7
Approval application for plan to return business license
8. Self-Assessment Form 8
Approval application for members of the liquidation team
9. Self-Assessment Form 9
Approval application for extension of liquidation implementation period

PART C: REPORTING CATEGORIES
No. Description Application Page
10. Self-Assessment Form 10
Reporting on determination of controlling shareholders and changes thereto
11. Self-Assessment Form 11
Reporting on implementation of GMS that approves conversion to Provider based on Sharia Principles

No. Description Application Page
12. Self-Assessment Form 12
Reporting on use of foreign workers 119
13. Self-Assessment Form 13
Reporting on implementation of education and training programs
14. Self-Assessment Form 14
Reporting on cooperation 127
15. Self-Assessment Form 15
Reporting on data exchange cooperation 130
16. Self-Assessment Form 16
Reporting on opening of offices other than head office
17. Self-Assessment Form 17
Reporting on cessation or closure of offices other than head office
18. Self-Assessment Form 18
Reporting on realization of changes in
Provider's name and/or Electronic System
19. Self-Assessment Form 19
Reporting on changes in address of head office and offices other than head office
20. Self-Assessment Form 20
Reporting on changes in business model 149
21. Self-Assessment Form 21
Reporting on realization of increase in paid-up capital
22. Self-Assessment Form 22
Reporting on implementation of GMS that approves change of ownership
23. Self-Assessment Form 23
Reporting on implementation of GMS that approves Merger or Consolidation
24. Self-Assessment Form 24
Reporting on implementation of changes in ownership
25. Self-Assessment Form 25
Reporting on implementation of Merger or
Consolidation
26. Self-Assessment Form 26
Reporting on implementation of settlement of rights and obligations
27. Self-Assessment Form 27
Reporting on realization of work plan and budget for liquidation implementation
28. Self-Assessment Form 28
Reporting on bankruptcy process 179

SELF-ASSESSMENT FORM 1 PROVIDER'S BUSINESS LICENSING APPLICATION FORM: 1 SELF-ASSESSMENT FORM PROVIDER'S BUSINESS LICENSING APPLICATION

Provider Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Brief description of the background of the business license application :
Provider Description:
(description of the Provider's history)
[……]
No. Shareholder Name Nominal (Rp) (%) Controlling/Non-Controlling 1. 2. 3.

Total
Part of the Provider's Group Structure:
(up to the ultimate controller)
[……]
Composition of the Board of Directors, Board of Commissioners, Sharia Supervisory Board, experts, and internal auditors of the Provider:
No. Position *) Name
Brief Description
Responsibilities
Information
Regarding
Concurrent Positions
Citizenship Domicile
Type of Certification
Financial Technology Field

1. Board of Directors
2. Board of Directors
3. Board of Directors

Board of
Commissioners
5.
Board of
Commissioners
6.
Sharia
Supervisory
Board
7. Experts

8. Internal Auditor
9. Etc.
   (please also elaborate if the Provider plans to use foreign workers) *) completed with job titles at each Provider NO. LEGAL BASIS DESCRIPTION COMPLETENESS YES NO NOTES Business Licensing Application Letter
10. The business licensing application is submitted using
    the format in Appendix 2 of POJK Number
    10/POJK.05/2022 and signed by the Board of Directors
    Article 9 paragraph (1)
    POJK Number
    10/POJK.05/2022
    Name of signatory:
    [......]
11. Copy of the establishment deed of the legal entity accompanied by
    evidence of approval from the competent authority
    Article 9 paragraph (1)
    letter a POJK Number
    10/POJK.05/2022
    Establishment data of the Provider: [......]
    Number and date of the establishment deed:
    [......]
    Number and date of evidence of approval from the competent authority:
    [......]
    The deed must at least contain:

a. name and domicile; Provider Name: [......]
Domicile: [.........] b. purpose and objectives as well as business activities; Purpose and objectives as well as business activities: [……]
c. paid-up capital; Amount of paid-up capital: [......]
d. ownership; Ownership data: [......] e. composition of authority, responsibilities, and term of office of members of the Board of Directors, members of the Board of Commissioners, and/or members of the DPS Authority, responsibilities, and term of office of members of the Board of Directors and members of the Board of Commissioners:
[......]
3. Copy of the deed of amendment to the Articles of Association accompanied
by evidence of approval, and/or letter of acceptance of notification from the competent authority, if any
Article 9 paragraph (1)
letter b POJK Number
10/POJK.05/2022
Data of all changes to the
Provider's Articles of Association
(if any):

1. Number and date of deed:
   [......]
   Number and date of evidence of approval and/or acceptance of notification from the competent authority:
   [......]
   Substance of the change to the Articles of Association:
   [......]
2. Etc.
3. List of shareholders including details of the size of each share ownership up to the
   last shareholder and/or beneficial owner, and list of other companies owned by shareholders
   Article 9 paragraph (1)
   letter c POJK Number
   10/POJK.05/2022
   (explained in the form of a chart and description) Last owner:
4. [……] amounting to [……]% or
   Rp[……]
5. Etc.
   Total foreign ownership both directly and indirectly:
   [.........]% or Rp[……]

In the event of foreign ownership, attach a photocopy of the cooperation agreement between the shareholder that is a foreign legal entity and the Indonesian shareholder.
5. Data of individual shareholders: Article 9 paragraph (1)
letter d POJK Number
10/POJK.05/2022 a. photocopy of identification in the form of an identity card or passport that is still valid; For foreign citizens, can also be proven with a Temporary Stay Permit Card (KIMS/KITAS) or Permanent Stay Permit Card (KITAP)

1. Name: [.........]
   ID/Passport Number:
   [.........]
   Validity period of identity:
   [.........]
2. Etc.
   b. photocopy of taxpayer identification number;

c. curriculum vitae in accordance with format 3
of the Appendix of POJK Number 10/POJK.05/2022 with a recent 4 x 6 cm color photo attached; and Supporting documents include:

1. photocopy of the latest diploma;
2. photocopy of expertise certificates (if any);
3. photocopy of certificates of passing or attendance
   at training previously attended;
4. work history documents in the form of
   recommendation letters and letters of intent to resign from other previous companies for prospective Board of Directors members;
5. awards relevant to the financial industry previously achieved (if any); and
6. skills mastered and proficiency in Indonesian/foreign languages
   Curriculum vitae and color photo in the name of:

1. Mr./Ms. [……]
2. Etc.
   In the event that the shareholder is a foreign citizen, the photo submitted must meet visa standards and can be processed through biometric applications d. statement letter from individual shareholders consisting of:

1. capital deposits do not come from loans;
2. capital deposits do not come from money laundering activities, terrorism financing, weapons of mass
   proliferation financing, and other financial crimes;
3. not listed in the list of bad credits and/or financing;
4. never sentenced for committing criminal offenses in the field of financial services business
   and/or economy based on a court decision that has had permanent legal force within the last 5 (five) years;
5. never sentenced for committing criminal offenses based on a court decision that has had permanent legal force within the last 5 (five) years;
6. never declared bankrupt or guilty causing a company/business to be declared bankrupt based on a court decision that has had permanent legal force within the last 5 (five) years;
7. never been a shareholder,
   member of the board of directors, member of the board of commissioners, or member of the DPS in a financial services company

2. Etc.

whose business license was revoked due to violations within the last 5 (five) years
6. Data of corporate shareholders: Article 9 paragraph (1)
letter d POJK Number
10/POJK.05/2022 a. copy of the establishment deed of the legal entity, including the articles of association including amendments to the articles of association regarding business activities, capital, shareholder structure, and management that are latest (if any), accompanied by evidence of approval, consent, registration, and/or letter of acceptance of notification from the competent authority; Deed No.: [......] Date: [......] Notary: [......] Substance: [......] Ministry of Law and Human Rights approval Number: [......] Date: [......] Data of all changes to the company's articles of association (if any):

1. Number and date of deed:
   [......]
   Number and date of evidence of approval and/or acceptance of notification from the competent authority:
   [......]
   Substance of the change to the articles of association:
   [......]
2. Etc.
   b. financial reports audited by a public accountant that have been signed by the directors or equivalent of the shareholder; Audited financial reports for the period: [......] Registered/Unregistered KAP *) at OJK *) strike out what is not needed
   c. latest non-consolidated financial report
   before capital deposit that has been
   Audited non-consolidated financial reports for the period: [......]

signed by the directors or equivalent of the shareholder; Type of assets in the last monthly financial report (before capital deposit) used to make capital deposits to the Provider: [……] d. photocopy of taxpayer identification number; Name: [......] NPWP Number: [......] e. data of directors or equivalent on the legal entity of the shareholder:

1. photocopy of identification in the form of an identity card
   or passport that is still valid;
   For foreign citizens, can also be proven with a Temporary Stay Permit Card (KIMS/KITAS) or Permanent Stay Permit Card (KITAP)

1. Name: [.........]
   Position: [.........]
   ID/Passport Number:
   [.........]
   Validity period of identity:
   [.........]
2. Etc.

In the event that the Board of Directors consists of foreign citizens, the submitted photos must meet visa standards and can be processed through a biometric application.

2. Photocopy of the Taxpayer Identification Number (NPWP); and

1. Name: [......]
   NPWP Number: [......]
2. Etc.

3. Curriculum vitae completed with the latest 4 x 6 cm color passport photo according to Format 3 of the Appendix to POJK Number 10/POJK.05/2022; and
   Supporting documents include:
   a) Photocopy of the highest diploma; b) Photocopy of expertise certificates (if any); Curriculum vitae and passport photo in the name of:

1. Mr./Ms. [.........]
2. Etc.

c) Photocopy of graduation certificates or attendance certificates for training previously attended; d) Employment history documents consisting of recommendation letters and a letter of intent to resign from the previous company for prospective Directors; e) Awards relevant to the financial industry previously achieved (if any); and f) Skills mastered and proficiency in Indonesian/foreign languages.

f. Statement letter from the legal entity represented by the Board of Directors or equivalent, consisting of:

1. Capital deposits do not originate from loans;
2. Capital deposits do not originate from money laundering, terrorism financing, weapons of mass destruction proliferation financing, and other financial crimes;
   Statement letter from the legal entity represented by the Board of Directors or equivalent, which has been fully filled out, properly stamped, and signed by the relevant party:

1. Mr./Ms. [……]

3. Not listed in the list of non-performing credits and/or financing;
4. Never sentenced for committing criminal offenses in the field of financial services business and/or the economy based on a court decision that has acquired permanent legal force within the last 5 (five) years;
5. Never sentenced for committing criminal offenses based on a court decision that has acquired permanent legal force within the last 5 (five) years;
6. Never declared bankrupt or guilty causing a company/corporation to be declared bankrupt based on a court decision that has acquired permanent legal force within the last 5 (five) years;
7. Never been a shareholder in a financial services company whose business license was revoked due to violations within the last 5 (five) years; and

2. Etc.

8. Statement meeting integrity aspects, financial feasibility aspects, and not currently undergoing a competency and propriety assessment process at a financial services institution.

7. Copy of government regulations regarding state capital participation in the establishment of the Provider, in the event that the shareholder is the central government.
   Article 9 paragraph (1) letter d POJK Number 10/POJK.05/2022
   Government regulation number:
   [……]

8. Copy of regional regulations regarding regional capital participation in the establishment of the Provider, in the event that the shareholder is the regional government.
   Article 9 paragraph (1) letter d POJK Number 10/POJK.05/2022
   Regional regulation number:
   [……]

9. Photocopy of annual tax notification letters for the last 2 (two) years prior to capital participation for prospective individual shareholders.
   Article 9 paragraph (1) letter e POJK Number 10/POJK.05/2022
   Tax Return (SPT) photocopy for Mr./Ms. [……] SPT Period: year [……] Taxable income:
   Rp[……]
   Asset list: [……]
   Total assets: Rp [……]

Liability list: [……]
Total liabilities: Rp[……]
Assets used as the source of capital participation funds in the SPT and supporting documents: [……]

10. Other documents showing financial capability and fund sources for prospective individual shareholders.
    Article 9 paragraph (1) letter f POJK Number 10/POJK.05/2022
    Asset list: [……]
    Total assets: Rp[……]
    Liability list: [……]
    Total liabilities: Rp[……]

11. Photocopy of proof of paid-up capital in the form of:
    Article 9 paragraph (1) letter g POJK Number 10/POJK.05/2022
    a. Cash deposit proof from shareholders; Transaction date: [……] Depositing bank: [……]

Depositor name: [……]
Receiving bank: [……]
Receiver name: [……]
Capital deposit nominal (original currency): [……] Capital deposit nominal:
Rp[……] b. Statement of account of the prospective Provider from the date of capital deposit from shareholders until the date of business license application; and Account name: [……] Account number: [……] Bank name: [……] Statement of account period: [… s/d …]
c. Photocopy of proof of deposited capital placement in the form of time deposits in the name of the respective Provider at:
Account name: [.......]
Account number: [.......]

1. one of the general banks, sharia general banks, or sharia business units of general banks in Indonesia for conventional Providers; or
2. one of the sharia general banks or sharia business units of general banks in Indonesia for Providers based on Sharia Principles, legalized by the bank, which remains valid during the business license application process.
   Bank name: [.......]
   Deposit period: […. s/d ….]

12. Documents proving that paid-up capital does not originate from loans, including:
    a. Information regarding shareholders from the financial services information system; b. Equivalent documents from other national authorities;
    c. Bank statements; and
    d. Others.
    Article 9 paragraph (1) letter h POJK Number 10/POJK.05/2022

13. Data of Board of Directors members, Board of Commissioners members, and/or Sharia Supervisory Board (DPS) members:
    Article 9 paragraph (1) letter i and letter m POJK Number 10/POJK.05/2022
    DPS member data is only applicable for Providers conducting business activities based on Sharia Principles.

a. Photocopy of identification cards such as ID cards or valid passports; For foreign citizens, this can also be proven with a Temporary Stay Permit Card (KIMS/KITAS) or Permanent Stay Permit Card (KITAP).

1. Name: [......]
   Position: [......]
   ID/Passport Number: [......]
   Validity period of identity:
   [......]
2. Etc.
   b. Photocopy of Taxpayer Identification Number (NPWP); 1. Name: [......] NPWP Number: [......]
3. Etc.
   c. Curriculum vitae and supporting documents completed with the latest 4 x 6 cm color passport photo according to Format 3 of the Appendix to POJK Number 10/POJK.05/2022;
   Supporting documents include:

1. Photocopy of the highest diploma;
   In the event that the Board of Directors and Board of Commissioners are foreign citizens, the submitted photos must meet visa standards and can be processed through a biometric application.

2. Photocopy of expertise certificates (if any);

3. Photocopy of graduation certificates or attendance certificates for training previously attended;

4. Employment history documents consisting of recommendation letters and a letter of intent to resign from the previous company for prospective Directors;

5. Awards relevant to the financial industry previously achieved (if any); and

6. Skills mastered and proficiency in Indonesian/foreign languages.
   d. Proof of experience at a financial services institution consisting of a recommendation letter or termination letter from the financial services institution; Experience at a financial services institution is:

7. Managerial experience of at least 2 (two) years in credit/financing, risk management, and/or finance for Directors;

8. Operational experience of at least 1 (one) year at a financial services institution conducting business activities based on Sharia Principles for Directors of Providers conducting business activities based on Sharia Principles; and

1. Name: [......]
   Letter number: [......]
   Financial services institution:
   [......]
   Years of experience: [......]
2. Etc.

3. Experience of at least 2 (two) years at the managerial level for the Board of Commissioners.
   e. Writing regarding work plans to be carried out after appointment to the targeted position, including:
4. Vision and mission;
5. Programs to be carried out during the term of office; and
6. Targets to be achieved during the term of office.
   f. Statement letter containing the following statements:
7. Meeting integrity aspects, financial reputation aspects, and not currently undergoing a competency and propriety assessment process at a financial services institution;
8. Not listed in the list of non-performing credits and/or financing;
9. Never sentenced for committing criminal offenses in the field of financial services and/or the economy based on a court decision that has acquired permanent legal force within the last 5 (five) years;
   Statement letter that has been fully filled out, properly stamped, and signed:

1. Mr./Ms. [......]
2. Etc.

4. Never sentenced for committing criminal offenses based on a court decision that has acquired permanent legal force within the last 5 (five) years;
5. Never declared bankrupt or declared guilty causing a business entity to be declared bankrupt based on a court decision that has acquired permanent legal force within the last 5 (five) years ending; and
6. Never been a shareholder, director, or member of the Board of Commissioners at a financial services company whose business license was revoked due to violations within the last 5 (five) years.

For foreign citizens specifically, attach equivalent documents to the certificate of good conduct issued by the original authority of the foreign citizen's country or the foreign legal entity, legalized by the Embassy of the Republic of Indonesia in the country of origin of the foreign citizen or the foreign legal entity, and accompanied by a translation into Indonesian.

g. Proof of residence permit and work permit from competent authorities for foreign citizen members of the Board of Directors and foreign citizen members of the Board of Commissioners domiciled in Indonesia. Name: [......] Position: [......] Permit number: [......] Date: [......]

14. Proof of work competency certificates from professional certification bodies in the field of financial technology registered with the Financial Services Authority (OJK) for the Board of Directors and Board of Commissioners.
    Article 9 paragraph (1) letter j POJK Number 10/POJK.05/2022
15. Name: [......]
    Position: [......]
    Issuing institution:
    [......]
    Certificate number: [......]
    Certificate date: [......]

Certificate validity period:
[……]
2. Etc.

Operational readiness evidence supporting business activities at least consists of:
15. Business License Number (NIB) from the competent authority.
Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
NIB or other relevant letters.

16. Letter of recommendation from an association, including information regarding:

1. Track record of key parties;
2. Key parties' understanding of the business process;
3. Compliance of electronic system data access with applicable laws and regulations;
4. Track record of the prospective Provider; and/or
5. Readiness of the prospective Provider's management.
   Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
   Letter number: [……]
   Letter date: [……]

17. Organizational structure completed with job descriptions and responsibilities of each organizational unit, which at least describes the existence of risk management, internal audit, and consumer complaint handling functions.
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
    This is also supplemented with information on the relationships and backgrounds of Board of Directors members, Board of Commissioners members, and shareholders briefly.

18. Human resource qualifications:
    a. Proof of expertise and/or at least 3 (three) years of experience in information technology for information technology workforce; and
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
    Name: [......]
    Certificate number: [......]
    Date: [......]
    Certificate issuer: [......]
    Work experience: [......] b. Proof of expertise and/or experience for workforce operating the internal audit unit.
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
    Name: [......]
    Certificate number: [......]
    Date: [......]
    Certificate issuer: [......]
    Work experience: [......]

19. Provider operational guidelines at least including:
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
    Guideline number: [......]

a. Guidelines or procedures regarding the credit scoring process; b. Financing distribution;
c. Implementation of anti-money laundering and counter-terrorism financing programs, as well as weapons of mass destruction proliferation financing prevention;
d. Financing repayment acceptance; e. Financing collection; f. Escrow account and virtual account management; g. Use of electronic signatures; h. Information security management system;
i. Internal control;
j. Drafting of financing agreements; k. Partnership cooperation;
l. Good corporate governance;
m. Utilization and protection of user data; n. Data and information management; o. Real-time and periodic reporting; and p. User complaint resolution. Effective date of guideline implementation: [......] Signed by: [......]

20. List of fixed assets and inventory.
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
    Fixed asset list:
    a. [......] b. [......]

c. Etc.
Inventory list:
a. [......] b. [......]
c. Etc.

21. Proof of ownership or control of the office building showing the Provider's office address, along with photos of the building exterior and interior, and room layout.
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022
    The aforementioned documents can be in the form of lease contracts or other proofs showing ownership of the office building. Proof/letter of office ownership Number: [......] Date: [......] Address: [......]

22. Documents related to electronic systems:
    Article 9 paragraph (1) letter k POJK Number 10/POJK.05/2022

a. Proof of ownership or control of electronic systems such as websites and/or mobile applications;

1. Ownership proof includes, among others, proof of electronic system development, proof of purchase and sale of electronic systems, a statement letter that the electronic system is owned by the Provider, and/or other documents deemed by the Financial Services Authority to prove ownership of the aforementioned electronic system.
2. Control proof includes, among others, a statement letter stating that the Provider has access, capability, and/or authority to use, modify, and delete the electronic system.
   Ownership proof
   Number: [......]
   Date: [......]
   Type of ownership proof: [......]
   Statement letter signed by:

1. Mr./Ms. [......]
2. Etc.
   Control proof
   Statement letter signed by:
3. Mr./Ms. [......]
4. Etc.
   b. Penetration test results report of the electronic system from an institution recognized by the competent authority; Number: [......] Date: [......]

Competent authority:
[......]
c. Supporting documents for electronic system readiness consisting of the implementation of electronic system governance, including standard operating procedures and electronic system flowcharts;
SOP Number: [......]
SOP Title: [......]
SOP implementation effective date: [......]
Signed by: [......] d. Supporting documents for cooperation with third parties:

1. Escrow account and virtual account agreements; Agreement number: [......]
   Agreement date: [......]
   Escrow account and virtual account provider:
   [......]
   Signed by: [......]

2. Electronic signature provision agreements with electronic certification service providers; and
   Agreement number: [......]
   Agreement date: [......]
   Electronic certification service provider: [......]
   Signed by: [......]

3. Documents for credit risk mitigation for fund providers.
   Risk mitigation documents include a) Agreements with special fund account providers; b) Cooperation agreements with external collection services; c) Cooperation agreements with insurance/guarantees; and d) Cooperation agreements with credit scoring.

1. Agreement number: [......]
   Agreement date: [......]
   Other party: [......]
   Signed by: [......]
2. Etc.
   e. Draft implementation agreement for IT-Based Joint Financing (LPBBTI); Provider-funder agreement Agreement name: [......]

Signed by (Provider party): [......]
Funder-fund receiver agreement
Agreement name: [......]
Signed by (Provider party): [......] f. Screenshots of the Electronic System such as websites and/or mobile applications; Website name: [......] Mobile application name: [......] g. Data center and disaster recovery center cooperation agreements (if using third parties) or proof of ownership of data centers and disaster recovery centers; and Cooperation agreement Agreement number: [......] Agreement date: [......] Other party: [......] Signed by: [......]

Proof of ownership
Proof of ownership number:
[......]
Ownership effective date:
[......]
Location: [......]
Signed by: [......] h. Photocopy of Taxpayer Identification Number (NPWP) Name: [......] NPWP Number: [......]

23. Business feasibility study for the first 3 (three) years.
    The business feasibility study at least contains:
    a. Vision, mission, and business strategy; b. Management policies and plans, including:

1. Business activity plans;
2. Business activity development or expansion plans;
3. Capital plans;
   Article 9 paragraph (1) letter l POJK Number 10/POJK.05/2022
   Explanation consisting of brief descriptions of each aspect of the business feasibility study:

1. Business activity plan:
   [......]
2. Business activity development
   or expansion plan: [......]

4. Financing plans;
5. Office network or distribution channel development and/or change plans;
6. Organization, human resources, and/or information technology development plans; and
7. Activities to increase financial literacy and inclusion plans;
   c. Initial financial position report;
   d. Monthly projections of:
8. Financial position reports;
9. Comprehensive income statements; and
10. Cash flow statements,
    along with the assumptions used; and e. Financing projections.

3. Capital plan: [......]

4. Financing plan: [......]

5. Office network development
   and/or change plan or distribution channel: [......]

6. Organization, human resources
   development, and/or information technology: [......]

7. Activities to increase
   financial literacy and inclusion [......]

8. Additional documents for Providers conducting business activities based on Sharia Principles:
   Article 9 paragraph (1) letter m POJK Number 10/POJK.05/2022

a. Copy of the Minutes of the General Meeting of Shareholders (RUPS) regarding the appointment of DPS members, accompanied by a receipt letter from the competent authority; RUPS Minutes Deed Deed number: [......] Date: [......] Notary: [......] Substance: [......] Receipt letter Letter number: [......] Date: [......] Competent authority:
[......] b. Copy of the Articles of Association stating that one of the company's purposes is to conduct business activities based on Sharia Principles, which has been approved/approved by the competent authority; Deed number: [......] Date: [......] Notary: [......]

Substance: [......]
c. Escrow account and virtual account cooperation agreements with banks conducting Sharia Principles;
Agreement number: [......]
Agreement date: [......]
Bank providing escrow account and virtual account: [......]
Signed by: [......] d. Proof of DPS member appointment and proof of approval by the National Sharia Board regarding the appointment of DPS members; and Appointment proof Letter number: [......] Date: [......] e. DPS approval of the business model to be marketed regarding its compliance with Sharia Principles, at least including:

1. Provider's business model;
2. Economic benefit calculation of financing;
3. Marketing methods; and
4. Examples of Sharia contracts.

25. Confirmation from the supervisory authority in the country of origin of the foreign party, if there is direct participation by a foreign legal entity that has a supervisory authority in its country of origin.
    Article 9 paragraph (1) letter n POJK Number 10/POJK.05/2022
    Country name: [......]
    Institution name: [......]
    Letter number: [......]
    Date: [......]
    Confirmation substance: [......]

26. Proof of payment of licensing fees for the issuance of business licenses.
    Article 9 paragraph (1) letter o POJK Number 10/POJK.05/2022
    OJK Information Reception System (SIPO) Number: [......]
    Payment date:
    [......]
    Amount paid: [......]
    Additional notes (if necessary):

We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out according to the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City) [……], (Date) [……]

Board of Directors [………………..] signature
[Full Name]

Note:

1. Filling method: click twice on the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM 2 SELF-ASSESSMENT FORM
APPLICATION FOR APPROVAL OF CONVERSION FROM CONVENTIONAL PROVIDER TO SHARIA-BASED PROVIDER FORM: 2 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF CONVERSION FROM CONVENTIONAL PROVIDER TO SHARIA-BASED PROVIDER Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/handphone, e-mail) :
Sharia Provider Name :
Brief description of the background of the approval request for conversion:
Provider Description:
(description of the Provider's history)
[……]

No. Name of Shareholder Nominal (Rp) (%) Controlling/Non-Controlling 1. 2. 3. Total Provider Group Structure Section:
(up to the last shareholder and/or beneficial owner) [……] Composition of the Board of Directors, Board of Commissioners, Sharia Supervisory Board, experts, and internal auditors of the Provider:
No. Position *) Name
Brief Description
Responsibilities
Information
Regarding
Concurrent Positions
Citizenship Domicile
Type of Certification
Field of Financial
Technology

1. Board of Directors
2. Board of Directors
3. Board of Directors

Board of
Commissioners

Board of
Commissioners
6.
Sharia Supervisory
Board
7. Experts
8. Internal Auditor
9. Etc.
*) supplemented with the naming of positions at each Provider NO. DESCRIPTION OF LEGAL BASIS COMPLETENESS YES NO NOTES

1. The application for approval of conversion is submitted using Format 4 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors.
   Article 10 paragraph (5)
   POJK Number
   10/POJK.05/2022

2. The Provider meets: Article 10 paragraph (2)
   POJK Number
   10/POJK.05/2022 a. the required minimum equity; and Total equity: [……] b. the conversion does not harm users.

3. The conversion plan has been included in the business plan as referred to in the Financial Services Authority Regulation regarding the business plan of non-bank financial services institutions.
   Article 10 paragraph (3)
   POJK Number
   10/POJK.05/2022
   The conversion plan has been included in the business plan year: [.........]

4. Proof of announcement regarding the conversion plan and the impact of the conversion on Users via the Electronic System such as websites and/or mobile applications.
   Article 10 paragraph (5)
   letter a POJK Number
   10/POJK.05/2022

5. Draft Minutes of the General Meeting of Shareholders (RUPS) approving the conversion into a Sharia Principle-based Provider.
   Article 10 paragraph (5)
   letter b POJK Number
   10/POJK.05/2022

6. Draft amendment to the Articles of Association containing:
   a. name based on Sharia Principles; b. the purpose and objective of the Provider based on Sharia Principles to conduct business activities based on Sharia Principles; and
   c. powers and responsibilities of the DPS.
   Article 10 paragraph (5)
   letter c POJK Number
   10/POJK.05/2022

7. The latest audited financial report.
   Article 10 paragraph (5)
   letter d POJK Number
   10/POJK.05/2022
   Audited financial report period: [……]

KAP registered/not registered *) with OJK
*) strike out what is not needed
8. Plan for settling the rights and obligations of Users Article 10 paragraph (5)
letter e POJK Number
10/POJK.05/2022
9. Initial financial report projections from business activities
of the Organizer based on Sharia Principles resulting from conversion
Article 10 paragraph (5)
letter f POJK Number
10/POJK.05/2022
10. Work plan related to business activities based on
Sharia Principles to be carried out for the first 3 (three) years after obtaining a business license as an Organizer based on Sharia Principles, containing at least:
a. work systems and procedures; b. Organizer's business model;
c. calculation of financing economic benefits;
d. marketing methods; e. examples of Sharia contracts; f. feasibility study of market opportunities and economic potential;
Article 10 paragraph (5)
letter g POJK Number
10/POJK.05/2022
Explanation in the form of descriptions for each point:
a. [……] b. [……]
c. [……]

g. plan for Sharia financing disbursement and steps taken to realize the aforementioned plan; and h. monthly projections of:

1. financial position reports;
2. comprehensive income statements; and
3. cash flow statements,
   along with the assumptions used

11. Draft cooperation agreement for escrow account and
    virtual account with a bank operating on
    Sharia Principles
    Article 10 paragraph (5)
    letter h POJK Number
    10/POJK.05/2022
    Additional information (if needed):
    We, the undersigned, declare that:
12. The Self-Assessment Form above has been filled out according to the actual situation and has been completed with documents
    as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
13. The documents submitted online are true and identical to the original documents.
    (city)[……], (date)[……]
    Board of Directors [……] signature

[Full Name]
Note:

1. Filling method: click twice in the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 3 APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE FORM: 3 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF OWNERSHIP CHANGE Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Background of the planned ownership change :
Form of ownership change of Shareholders in the Organizer which is not a public company Shareholders of the Organizer's shareholders which is not a public company Controlling shareholders in the Organizer in the form of a public company Controlling shareholders of the Organizer's shareholders which is in the form of a public company Composition of ownership change:

Before Change After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%) Total 100 Total 100 NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Application for approval of ownership change
   is submitted using format 12
   Appendix POJK Number 10/POJK.05/2022 and
   signed by the Board of Directors
   Article 69 paragraph (1)
   POJK Number
   10/POJK.05/2022
2. Ownership change results in the existence of: Article 68 paragraph (3)
   POJK Number
   10/POJK.05/2022
   Business license decision letter number [……] dated [……] a. new shareholders; and/or b. change of controlling shareholders, within a period of 3 (three) years from the date of the business license from OJK
3. The ownership change plan has been included in
   the business plan as referred to in the Financial Services Authority Regulation regarding business plans of non-bank financial service institutions
   Article 68 paragraph (4)
   POJK Number
   10/POJK.05/2022
   Conversion plan has been included in the business plan year: [……] Include description regarding capital projections and planned capital changes
4. Ownership change meets the provisions
   as referred to in Article 3:
   Article 68 paragraph (5)
   POJK Number
   10/POJK.05/2022 a. Organizer's shares are owned by:

1. Indonesian citizens and/or Indonesian legal entities; or
2. Indonesian citizens and/or Indonesian legal entities
   together with foreign legal entities and/or foreign citizens b. foreign citizens become owners through transactions on the stock exchange
   c. Indonesian legal entities do not include entities in the form of cooperatives

d. foreign ownership in the Organizer, both directly and indirectly, does not exceed 85% of paid-up capital, except for Organizers that are public companies and trade their shares on the stock exchange Before Change (%) After Change (%) Direct Indirect
5. Draft minutes of the Extraordinary General Meeting of Shareholders (EGMS) approving the ownership change in the event that the ownership change
requires EGMS approval
Article 69 paragraph (1)
letter a POJK Number
10/POJK.05/2022
Draft EGMS minutes contain substance before and after the planned change in share ownership and approval by the shareholders Other material information (if any): [……]
6. Plan for ownership structure up to the
ultimate ownership:
Article 69 paragraph (1)
letter b POJK Number
10/POJK.05/2022

a. attachment of shareholder list including details of each share ownership up to the ultimate ownership and/or beneficial owners Shareholder list submitted in the form of a chart with information:
List of current names and composition of shareholders:
a. [……] ownership of
[……] % b. [……] ownership of
[……] %
Planned list of names and composition of shareholders:

1. [……] ownership of
   [……] %

2. [……] ownership of
   [……] % b. attachment of list of other companies owned by shareholders List of other companies owned by shareholders:

3. [……]

4. Etc.
   c. attachment of Board of Directors statement letter of the Organizer
   signed with a stamp that states the beneficial owner party of the Organizer Describe the brief profile of the beneficial owner and the form of control by the beneficial owner over the Organizer

5. Copy of government regulations regarding state capital participation
   for the Republic of Indonesia for ownership change of the Organizer, in the event that the shareholder is the central government
   Article 69 paragraph (1)
   letter c POJK Number
   10/POJK.05/2022
   Government regulation number:
   [……]

6. Copy of regional regulations regarding the statement of
   district/city government capital for ownership change, in the event that the shareholder is a regional government
   Article 69 paragraph (1)
   letter d POJK Number
   10/POJK.05/2022
   Regional regulation number:
   [……]

7. Draft deed of transfer of share rights or draft deed of
   share sale and purchase
   Article 69 paragraph (1)
   letter e POJK Number
   10/POJK.05/2022
   Draft deed of transfer of share rights from:
   Mr./Ms. [……]
   PT [……] to:
   Mr./Ms. [……]

PT [……]
Draft share sale and purchase deed [……] shares with a nominal value of Rp[……] from [……] to [……], with a price of Rp[……]
10. Latest financial report audited by a public accountant
Article 69 paragraph (1)
letter f POJK Number
10/POJK.05/2022
Audited financial report for the period [……] KAP registered/not registered *) with OJK *) strike out what is not needed
11. Organizer's proforma financial report Article 69 paragraph (1)
letter f POJK Number
10/POJK.05/2022
Proforma financial report for the period [……]
12. Photocopy of tax notification for the last 2 (two) years
before the capital injection is carried out and other documents showing the financial ability and source of funds of the prospective shareholder individual
Article 69 paragraph (1)
letter g POJK Number
10/POJK.05/2022
Photocopy of SPT for Mr./Ms. [……]
SPT Period: year [……]
Taxable income:
Rp[……]

Asset list: [……]
Total assets: Rp[……]
Liability list: [……]
Total liabilities:
Rp[……]
Type of assets used as the source of funds for capital injection: [……] SPT photocopy must be submitted completely by attaching the asset and liability appendices)
13. Confirmation from the supervisory authority in the country of origin
of the foreign party, if there is direct participation by
Article 69 paragraph (1)
letter h POJK Number
10/POJK.05/2022
Country name: [……]
Institution name: [……]

foreign legal entities that have a supervisory authority in their home country Letter number: [……] Date: [……] Substance of confirmation: [……]
14. Debtor data documents from the Financial Services Information System (SLIK)
of the Financial Services Authority from the prospective shareholder due to ownership change or documents considered equivalent by the Financial Services Authority
Article 69 paragraph (1)
letter i POJK Number
10/POJK.05/2022
15. Data of Board of Directors members, Board of Commissioners members,
and/or DPS members in the event of changes to the Board of Directors, Board of Commissioners, and/or DPS
Article 69 paragraph (1)
letter j POJK Number
10/POJK.05/2022 a. photocopy of identification in the form of an identity card or valid passport; For foreign citizens, this can also be proven with a Temporary Stay Permit Card (KIMS/KITAS) or Permanent Stay Permit Card (KITAP)

1. Name: [......]
   Position: [......]
   ID/Passport Number: [......]
   Validity period of identity:
   [......]

2. Etc.
   b. photocopy of taxpayer identification number; 1. Name: [......] NPWP Number: [......]

3. Etc.
   c. curriculum vitae and supporting documents completed with a recent
   4 x 6 cm color photo according to format 3
   Appendix POJK Number 10/POJK.05/2022;
   Supporting documents include:

1. photocopy of the latest diploma;

2. photocopy of expertise certificates (if any);

3. photocopy of certificate of completion or attendance
   of training previously attended;

4. work history documents in the form of recommendation letters and letters of intent to resign from the previous company for prospective Directors;
   In the event that the Board of Directors and Board of Commissioners are foreign citizens, the photos submitted must meet visa standards and can be processed through biometric applications

5. awards relevant to the financial industry previously achieved (if any); and

6. skills mastered and proficiency in Indonesian/foreign languages
   d. proof of experience in financial service institutions in the form of recommendation letters or termination letters from financial service institutions; Experience in financial service institutions is:

7. managerial experience of at least 2 (two)
   years in the field of credit/financing, risk management, and/or finance for Directors;

8. operational experience of at least 1 (one)
   year in a financial service institution that carries out business activities based on Sharia Principles for Directors of Organizers that carry out business activities based on Sharia Principles; and

9. experience of at least 2 (two) years at
   the managerial level for the Board of Commissioners

1. Name: [......]
   Letter number: [......]
   Financial service institution:
   [......]
   Years of experience: [......]
2. Etc.

e. writing regarding the work plan to be carried out after being appointed to the position includes:

1. vision and mission;
2. programs to be carried out during the term of office;
   and
3. targets to be achieved during the term of office
   f. statement letter containing the statement:
4. meets integrity aspects, financial reputation aspects, and is not currently undergoing a suitability and propriety assessment process at a
   financial service institution;
5. is not listed in the list of bad credits and/or financing;
6. has never been sentenced for committing criminal acts in the field of financial services and/or the economy based on a court
   decision that has had permanent legal force within the last 5 (five) years;
7. has never been sentenced for committing criminal acts based on court
   Statement letter that has been filled out completely, stamped sufficiently, and signed:

1. Mr./Ms. [......]
2. Etc.

decisions that have had permanent legal force within the last 5 (five) years;
5) has never been declared bankrupt or declared guilty causing a business entity
to be declared bankrupt based on a court decision that has had permanent legal force within the last 5 (five) years; and
6) has never been a shareholder,
director, or board of commissioners member at a financial service company whose business license was revoked due to violations in the last 5 (five) years For foreign citizens, attach equivalent documents to the certificate of good conduct issued by the original authority of the country of origin of the foreign citizen or the foreign legal entity thereof, legalized by the Embassy of the Republic of Indonesia in the country of origin of the foreign citizen or the foreign legal entity thereof and accompanied by a translation into Indonesian

g. proof of residence permit and work permit letter from the competent authority for foreign citizen members of the Board of Directors and foreign citizen members of the Board of Commissioners who reside in Indonesia Name: [......] Position: [......] Permit letter number: [......] Date: [......]
16. Letter of recommendation from the association for prospective shareholders
Article 69 paragraph (1)
letter k POJK Number
10/POJK.05/2022
Letter number: [……]
Letter date: [……]
17. Data of individual shareholders: Article 69 paragraph (1)
letter l POJK Number
10/POJK.05/2022 a. photocopy of identification in the form of an identity card or valid passport; For foreign citizens, this can also be proven with a Temporary Stay Permit Card (KIMS/KITAS) or Permanent Stay Permit Card (KITAP)

1. Name: [.........]
   ID/Passport Number:
   [.........]
   Validity period of identity:
   [.........]
2. Etc.

b. photocopy of taxpayer identification number;
c. curriculum vitae according to format 3
Appendix POJK Number 10/POJK.05/2022 with
a recent 4 x 6 cm color photo attached; and Supporting documents include:

1. photocopy of the latest diploma;
2. photocopy of expertise certificates (if any);
3. photocopy of certificate of completion or attendance
   of training previously attended;
4. work history documents in the form of recommendation letters and letters of intent to resign from the previous company for prospective Directors;
5. awards relevant to the financial industry previously achieved (if any); and
6. skills mastered and proficiency in Indonesian/foreign languages
   Curriculum vitae and color photo in the name of:

1. Mr./Ms. [.........]
2. Etc.
   In the event that the shareholder is a foreign citizen, the photo submitted must meet visa standards and can be processed through biometric applications

d. statement letter of individual shareholders consisting of:

1. capital deposits do not come from loans;
2. capital deposits do not come from money laundering activities, terrorism financing, weapons of mass destruction proliferation financing, and other financial crimes;
3. is not listed in the list of bad credits and/or financing;
4. has never been sentenced for committing criminal acts in the field of financial service business
   and/or the economy based on a court decision that has had permanent legal force within the last 5 (five) years;
5. has never been sentenced for committing criminal acts based on court decision
   Statement letter that has been filled out completely, stamped sufficiently, and signed by the relevant party:

1. Mr./Ms. [……]
2. Etc.

that has had permanent legal force within the last 5 (five) years;
6) has never been declared bankrupt or guilty
that causes a company/business to be declared bankrupt based on court decision that has had permanent legal force within the last 5 (five) years; and
7) has never been a shareholder,
board of directors member, board of commissioners member, or DPS member at a financial service company whose business license was revoked due to violations in the last 5 (five) years
18. Data of corporate shareholders: Article 69 paragraph (1)
letter l POJK Number
10/POJK.05/2022 a. copy of the establishment deed of the legal entity, including the articles of association including amendments to the articles of association regarding business activities, capital, shareholder structure, and management that are the latest (if any), accompanied by proof of approval, consent, recording, and/or letter of acceptance of notification from the competent authority; Deed number: [......] Date: [......] Notary: [......] Substance: [......] Ministry of Law and Human Rights approval number [......]

Date: [......]
Data of all amendments to the company's articles of association (if any):

1. Deed number and date:
   [......]
   Number and date of proof of consent and/or acceptance of notification from the competent authority: [......] Substance of amendment to the articles of association: [......]
2. Etc.
   b. financial report audited by a public accountant that has been signed by the directors or the equivalent of the shareholder; Audited financial report for the period: [......]

KAP registered/not registered *) with OJK
*) strike out what is not needed
c. latest non-consolidated financial report
before capital deposit that has been signed by the directors or the equivalent of the shareholder; Non-consolidated financial report for the period: [......] Type of assets in the report in the latest monthly financial report (before capital deposit) used to make capital deposits to the Organizer: [……] d. photocopy of taxpayer identification number; Name: [......] NPWP Number: [......] e. data of directors or the equivalent in the legal entity of the shareholder:

1. photocopy of identification in the form of an identity card
   or valid passport;

1. Name: [.........]
   Position: [.........]

For foreign citizens, this can also be proven with a Temporary Stay Permit Card (KIMS/KITAS) or Permanent Stay Permit Card (KITAP) ID/Passport Number: [.........] Validity period of identity:
[.........]
2. Etc.
2) photocopy of taxpayer identification number; and 1. Name: [......]
NPWP Number: [......]
2. Etc.
3) curriculum vitae completed with a recent
4 x 6 cm color photo according to format 3 Appendix POJK Number 10/POJK.05/2022; and Supporting documents include:
a) photocopy of the latest diploma; b) photocopy of expertise certificates (if any); c) photocopy of certificate of completion or attendance of training previously attended; Curriculum vitae and color photo in the name of:

1. Mr./Ms. [.........]
2. Etc.
   In the event that the Board of Directors are foreign citizens, the photo submitted must meet visa standards and

d) work history documents in the form of recommendation letters and letters of intent to resign from the previous company for prospective Directors; e) awards relevant to the financial industry previously achieved (if any); f) skills mastered and proficiency in Indonesian/foreign languages can be processed through biometric applications f. statement letter of the legal entity represented by the director or the equivalent, consisting of:

1. capital deposits do not come from loans;
2. capital deposits do not come from money laundering activities, terrorism financing, weapons of mass destruction proliferation financing, and other financial crimes;
3. is not listed in the list of bad credits and/or financing;
4. has never been sentenced for committing criminal acts in the field of financial service business
   Statement letter that has been filled out completely, stamped sufficiently, and signed by the relevant party:

1. Mr./Ms. [……]
2. Etc.

and/or the economy based on a court decision that has had permanent legal force within the last 5 (five) years;
5) has never been sentenced for committing criminal acts based on court decision that has had permanent legal force within the last 5 (five) years;
6) has never been declared bankrupt or guilty
that causes a company/business to be declared bankrupt based on court decision that has had permanent legal force within the last 5 (five) years;
7) has never been a shareholder at a
financial service company whose business license was revoked due to violations in the last 5 (five) years; and
8) statement of meeting integrity aspects, financial
feasibility aspects, and not currently undergoing a suitability and propriety assessment process at a financial service institution

19. Proof of fund placement in escrow account
    and/or time deposit, if ownership change is carried out through cash deposits
    Article 69 paragraph (1)
    letter m POJK Number
    10/POJK.05/2022
    Include explanation regarding the flow of source funds for fund placement and proof supporting documents, among others bank statements of the prospective shareholder who will make the capital injection for a period of 3 months before placing the funds
20. Proof of prospective shareholder's fund readiness, among
    others:
21. proof of copy of deposit ownership or
    ownership of funds belonging to the prospective Shareholder at a bank according to the fair value reflected in the draft deed and/or share sale/transfer agreement;
22. proof of capital deposits that have been disbursed to
    the Organizer; and/or
23. bank statements for the last 3 (three) months
    Article 69 paragraph (1)
    letter n POJK Number
    10/POJK.05/2022
    Total deposit amount of
    Rp[……], consisting of:
24. Bank name: [……]
25. Bilyet number: [……]
26. Nominal amount: [……]
    Total capital deposit amount of
    Rp[……] consisting of:
27. Bank name: [……]
28. Deposit date: [……]

Additional information (if needed):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out according to the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (city)[……], (date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. Filling method: click twice in the box, then select “Checked”.
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 4 APPLICATION FOR APPROVAL OF PAID-UP CAPITAL INCREASE FORM: 4 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF PAID-UP CAPITAL INCREASE Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Brief description of the background of the paid-up capital increase :
Form of paid-up capital addition cash deposit retained earnings transfer stock dividends Composition of ownership change:
Before Change After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%)

Total 100 Total 100
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Paid-up capital increase has been included in
   the business plan
   Article 70 paragraph (2)
   POJK Number
   10/POJK.05/2022
   Conversion plan has been included in the business plan year: [……] Include description regarding capital projections and planned capital changes
2. Application for approval of paid-up capital increase
   is submitted using format 13
   Appendix POJK Number 10/POJK.05/2022 and
   signed by the Board of Directors
   Article 70 paragraph (3)
   POJK Number
   10/POJK.05/2022
3. Proof that capital does not come from loans:
   a. debtor data documents from the Financial Services Information System (SLIK) of the Financial Services Authority; or
   Article 70 paragraph (3)
   letter a POJK Number
   10/POJK.05/2022

b. documents considered equivalent by the Financial Services Authority
4. Proof of additional capital deposit Article 70 paragraph (3)
letter b POJK Number
10/POJK.05/2022

1. Proof of paid-up capital deposit
   Transaction date:
   [……]
   Depositing bank: [……]
   Depositor name: [……]
   Receiving bank: [……]
   Recipient name:
   [……]
   Capital deposit nominal
   (original currency):
   [……]
   Capital deposit nominal:
   Rp[……]

or
2. Financial statements
Providers that have been audited by a public accountant prior to capital increase, in the event that the paid-in capital increase is carried out in the form of transfer of retained earnings, transfer of loans, and/or stock dividends
5. Shareholder statement declaring
that the capital deposit does not originate from loans, terrorism financing, proliferation financing of weapons of mass destruction, and other financial crimes in the event that the capital increase is carried out in the form of cash deposit
Article 70 paragraph (3)
letter c POJK Number
10/POJK.05/2022
Statement letter signed by the shareholder as follows:
Mr/Mrs [……]
PT [……]

6. Tax notification letter for the last 2 (two) years
   and other documents showing the financial capacity and source of funds of the prospective shareholder individual
   Article 70 paragraph (3)
   letter d POJK Number
   10/POJK.05/2022
   Copy of Tax Return (SPT) for:
   Mr/Mrs [……]
7. SPT Period: Year [……]
   Taxable income:
   Rp[……]
   Asset list: [……]
   Total assets: Rp[……]
   Liability list: [……]
   Total liabilities:
   Rp[……]
8. Etc.
9. Shareholder financial statements that have been
   audited by a public accountant and/or the latest financial statements, in the event that the shareholder is a legal entity
   Article 70 paragraph (3)
   letter e POJK Number
   10/POJK.05/2022
   Shareholder financial statements, as follows:
10. Shareholder name:
    [.........]

Period of audited financial statements: [.........]
Registered/not registered KAP *) with OJK
*) strike out what is not needed
Period of the latest monthly financial statements: [.........]
Total equity: [.........]
Type of assets in the latest monthly financial statements (before capital deposit) used to make capital deposits to the Provider:
[……]
2. Etc.

8. Bank statements for individual shareholders Article 70 paragraph (3)
   letter f POJK Number
   10/POJK.05/2022
   Bank statements for a 3
   (three) month period prior to capital deposit and legalized by the Bank
9. Proof of funds placement in escrow account
   and/or time deposits, if ownership change is carried out via cash deposit
   Article 70 paragraph (3)
   letter g POJK Number
   10/POJK.05/2022
   Include an explanation regarding the flow of source of funds placement and supporting evidence, among others the prospective shareholder's bank statement who will make the capital investment for a 3-month period prior to placing the funds Additional information (if needed):
   We, the undersigned, declare that:
10. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
    as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
11. The documents submitted online are true and identical to the original documents.
    (City)[……], (Date)[……]
    Board of Directors [………………..]

signature
[Clear Name]
Note:

1. How to fill out: click twice on the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Joint Financing Services.

SELF-ASSESSMENT FORM 5 APPLICATION FOR APPROVAL OF CHANGES TO BOARD OF DIRECTORS MEMBERS, BOARD OF COMMISSIONERS MEMBERS, AND/OR DPS MEMBERS FORM: 5 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF CHANGES TO BOARD OF DIRECTORS MEMBERS, BOARD OF COMMISSIONERS MEMBERS, AND/OR DPS MEMBERS Provider Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Board of Directors, Board of Commissioners, and/or DPS Members Position *) Before Change After Change Number and Date of Letter of Approval for Competency and Propriety Assessment Board of Directors Board of Commissioners Sharia Supervisory Board Etc.

*) completed with the naming of positions at each Provider NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Application for approval of changes to Board of Directors members,
   Board of Commissioners members, and/or DPS members is submitted using format 14
   Appendix of POJK Number 10/POJK.05/2022 and
   signed by the Board of Directors
   Article 71 paragraph (3)
   POJK Number
   10/POJK.05/2022

2. The plan for changes to Board of Directors members, Board of Commissioners
   members, and/or DPS members has been included in the business plan as referred to in the Financial Services Authority Regulation regarding business plans for non-bank financial service institutions
   Article 71 paragraph (2)
   POJK Number
   10/POJK.05/2022
   Change plan has been included in the business plan year: [……]

3. Copy of RUPS Deed Article 71 paragraph (3)
   POJK Number
   10/POJK.05/2022
   Number: [.........]
   Date: [.........]
   Notary: [.........]
   Notary's domicile:
   [.........]

4. Data of Board of Directors members, Board of Commissioners
   members, and/or DPS members:
   Article 71 paragraph (3)
   POJK Number
   10/POJK.05/2022
   DPS member data is only applicable to Providers conducting business activities based on Sharia Principles a. copy of identification in the form of an identity card or valid passport; For foreign citizens, this can also be proven with a Temporary Residence Permit Card (KIMS/KITAS) or Permanent Residence Permit Card (KITAP)

5. Name: [......]
   Position: [......]
   ID/Passport Number: [......]
   Validity period of identity:
   [......]

6. Etc.
   b. copy of tax identification number; 1. Name: [......]
   Tax ID Number:
   [......]

7. Etc.

c. curriculum vitae and supporting documents
completed with the latest color passport photo measuring 4 x 6 cm according to format 3
Appendix of POJK Number 10/POJK.05/2022; and
Supporting documents in the form of:

1. copy of the latest diploma;
2. copy of expertise certificates (if any);
3. copy of certificate of passing or attendance
   at training previously attended;
4. work history documents in the form of
   recommendation letters and letters of intent to resign from other companies for prospective Board of Directors members;
5. awards relevant to the financial industry previously achieved (if any); and
6. skills mastered and proficiency in Indonesian/foreign languages
   In the event that the Board of Directors and Board of Commissioners are foreign citizens, the photos submitted must meet visa standards and can be processed through biometric applications d. proof of experience in financial service institutions in the form of recommendation letters or termination letters from financial service institutions;

1. Name: [......]
   Letter Number: [......]

Experience in financial service institutions is:

1. managerial experience of at least 2 (two)
   years in the fields of credit/financing, risk management, and/or finance for the Board of Directors;
2. operational experience of at least 1 (one)
   year in a financial service institution that conducts business activities based on Sharia Principles for the Board of Directors for Providers that conduct business activities based on Sharia Principles; and
3. experience of at least 2 (two) years at
   the managerial level for the Board of Commissioners Financial service institution:
   [......]
   Years of experience: [......]

2. Etc.
   e. writing regarding the work plan to be conducted after being appointed to the target position, including:

1. vision and mission;
2. programs to be carried out during the term of office;
   and
3. targets to be achieved during the term of office
   f. statement letter containing the following statements:
4. meets integrity aspects, financial reputation aspects, and is not currently undergoing a process
   Statement letter that has been filled out completely, with sufficient stamp duty, and signed:

assessment of competency and propriety at a financial service institution;
2) is not recorded in the list of non-performing loans and/or
financing;
3) has never been sentenced for committing criminal offenses in the field of financial services and/or
economy based on a court decision that has had permanent legal force within the last 5 (five) years;
4) has never been sentenced for committing criminal offenses based on a court decision that has had permanent legal force within the last 5 (five) years;
5) has never been declared bankrupt or declared guilty causing a business entity
to be declared bankrupt based on a court decision that has had permanent legal force within the last 5 (five) years; and
6) has never been a shareholder,
Board of Directors, Board of Commissioners at a financial service company whose business license was revoked due to

1. Mr/Mrs. [......]
2. Etc.

committing violations within the last 5 (five) years For foreign citizens, attach documents equivalent to a certificate of good conduct issued by the original authority of the foreign citizen's country of origin or the foreign legal entity that is legalized by the Embassy of the Republic of Indonesia in the country of origin of the foreign citizen or the foreign legal entity and accompanied by a translation into Indonesian g. proof of residence permit and work permit letter from the competent authority for:

1. Board of Directors members with foreign nationality; and
2. Board of Commissioners members with foreign nationality
   who reside in Indonesia
   Name: [......]
   Position: [......]
   Permit Number: [......]
   Date: [......]
   Compliance with Good Corporate Governance for Information Technology-Based Joint Financing Service Providers a. Board of Directors

5. The Provider has 2 (two) Board of Directors members Article 55 paragraph (1)
   POJK Number
   10/POJK.05/2022

6. Half of the Board of Directors members have managerial experience
   in financial service institutions of at least 2 (two) years in the fields of credit or financing, risk management, and/or finance
   Article 55 paragraph (2)
   POJK Number
   10/POJK.05/2022

7. Half of the Board of Directors members must have
   operational experience of at least 1 (one) year in a financial service institution that conducts business activities based on Sharia Principles
   Article 55 paragraph (3)
   POJK Number
   10/POJK.05/2022

8. Board of Directors members do not hold concurrent positions in
   other companies except as Board of Commissioners members or equivalent in at most 3 (three) companies other than the Provider
   Article 55 paragraph (4)
   POJK Number
   10/POJK.05/2022

9. At most half of the Board of Directors members
   are foreign citizens in the event that there is ownership of the Provider by a foreign legal entity of at least 25%
   Article 55 paragraph (5)
   POJK Number
   10/POJK.05/2022

10. All Board of Directors members reside in Indonesia Article 55 paragraph (6)
    POJK Number
    10/POJK.05/2022 b. Board of Commissioners

11. The Provider has at least 1 (one)
    Board of Commissioners member and at most equal to the number of Board of Directors members
    Article 56 paragraph (1)
    POJK Number
    10/POJK.05/2022

12. At least half of the Board of Commissioners members must have experience of at least 2
    two) years at the managerial level at a financial service institution
    Article 56 paragraph (2)
    POJK Number
    10/POJK.05/2022

13. Board of Commissioners members do not hold concurrent positions
    except in at most 3 (three) companies other than the Provider
    Article 56 paragraph (3)
    POJK Number
    10/POJK.05/2022

14. At most half of the Board of Commissioners members
    are foreign citizens in the event that there is ownership of the Provider by a foreign legal entity of at least 25%
    Article 56 paragraph (5)
    POJK Number
    10/POJK.05/2022

15. At least half of the Board of Commissioners members
    reside in Indonesia
    Article 56 paragraph (6)
    POJK Number
    10/POJK.05/2022

c. DPS
16. The Provider has at least 1 (one)
DPS member who receives a recommendation from the National Sharia Board
Article 57 paragraph (1)
POJK Number
10/POJK.05/2022
17. DPS members do not hold concurrent positions as
DPS members in more than 3 (three) other Sharia financial institutions
Article 57 paragraph (2)
POJK Number
10/POJK.05/2022
Additional information (if needed):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Clear Name]

Note:

1. How to fill out: click twice on the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Joint Financing Services.

SELF-ASSESSMENT FORM 6 APPLICATION FOR APPROVAL OF MERGER OR CONSOLIDATION FORM: 6 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF MERGER OR CONSOLIDATION Merger *) Name of Provider receiving the Merger :
Name of Provider merging into the other :
Consolidation *)
Name of Provider :
Name of Provider merging into the other :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Brief description of the background of the Merger or Consolidation :
Substance of the Merger or Consolidation
No.
Before Change
No.
After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%)

1. Provider A
   Shareholder
   Shareholder
   Total

2. Provider A
   Shareholder
   Shareholder
   Total

3. Etc.
   *) adjusted to the type of implementation plan of the Provider NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

4. Application for approval of Merger or
   Consolidation is submitted using format
   15 Appendix of POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 72 paragraph (5)
   POJK Number
   10/POJK.05/2022

5. Merger or Consolidation is included in the business
   plan
   Article 72 paragraph (3)
   POJK Number
   10/POJK.05/2022

6. Merger or Consolidation is carried out by
   Providers that have the same financing principle
   Article 72 paragraph (4)
   POJK Number
   10/POJK.05/2022

7. Summary of the draft Merger or Consolidation
   according to the provisions of the Law concerning limited liability companies, at least containing:
   a. company profile resulting from the Merger or Consolidation; b. key parties resulting from the Merger or Consolidation;
   c. Provider's business model;
   d. user targets; e. disbursement targets; and f. cooperation plan with the digital ecosystem
   Article 72 paragraph (5)
   letter a POJK Number
   10/POJK.05/2022

8. Draft RUPS deed approving
   the Merger or Consolidation
   Article 72 paragraph (5)
   letter b POJK Number
   10/POJK.05/2022

9. Draft Deed of Merger or Consolidation, which
   contains:
   a. The Merger or Consolidation does not reduce user rights; and
   Article 72 paragraph (5)
   letter c POJK Number
   10/POJK.05/2022

b. the financial condition of the company resulting from the Merger or Consolidation meets the minimum equity provisions
7. Draft ownership list, for Providers
that will carry out the Merger or Consolidation
Article 72 paragraph (5)
letter d POJK Number
10/POJK.05/2022
8. The latest financial statements that have been audited by
a public accountant registered with the Financial Services Authority at each Provider
Article 72 paragraph (5)
letter e POJK Number
10/POJK.05/2022
Audited financial statements period: [……]
9. Pro forma financial statements of the Provider resulting from
the Merger or Consolidation
Article 72 paragraph (5)
letter f POJK Number
10/POJK.05/2022
10. Organizational structure resulting from the Merger or
Consolidation
Article 72 paragraph (5)
letter g POJK Number
10/POJK.05/2022
11. List of shareholders and details of the size of
each share ownership up to the last shareholder and/or beneficial owner resulting from the Merger or Consolidation
Article 72 paragraph (5)
letter h POJK Number
10/POJK.05/2022

12. Business feasibility study for the first 3 (three) years
    of the Provider resulting from the Merger or Consolidation, at least containing:
    a. vision, mission, and business strategy; b. policies and management plans, including:

1. business activity plans;
2. plans for development or expansion of business
   activities;
3. capital plans;
4. financing plans;
5. plans for development and/or changes
   in office network or distribution channels;
6. plans for organizational development, human resources,
   and/or information technology; and
7. plans for activities to increase
   financial literacy and inclusion;
   c. initial financial position report;
   d. monthly projections of:
8. financial position reports;
9. comprehensive income statements; and
10. cash flow statements,
    along with the assumptions used; and
    Article 72 paragraph (5)
    letter i POJK Number
    10/POJK.05/2022

e. financing projections
13. The Provider meets the requirements: Article 72 paragraph (7)
POJK Number
10/POJK.05/2022 a. Merger or Consolidation does not reduce user rights; b. the financial condition of the Provider resulting from the Consolidation or Merger meets the minimum equity provisions; and Total equity: [……]
c. does not cause the Provider to violate
provisions as regulated in POJK Number
10/POJK.05/2022
Changes to Board of Directors members, Board of Commissioners members, and/or DPS members
14. Application for approval of the implementation plan
for the Merger or Consolidation as referred to in Article 72 paragraph (2) is submitted simultaneously with the application for competency and propriety assessment for prospective members of the Board of Directors, Board of Commissioners members, DPS members, and/or controlling shareholders of the Provider
Article 73 paragraph (1)
POJK Number
10/POJK.05/2022
If the intended Merger or
Consolidation results in changes to Board of Directors members, Board of Commissioners members, and/or controlling shareholders of the Provider

15. Data of Board of Directors members, Board of Commissioners
    members, and/or DPS members:
    Article 72 paragraph (6)
    POJK Number
    10/POJK.05/2022
    DPS member data is only applicable to Providers conducting business activities based on Sharia Principles a. copy of identification in the form of an identity card or valid passport; For foreign citizens, this can also be proven with a Temporary Residence Permit Card (KIMS/KITAS) or Permanent Residence Permit Card (KITAP)
16. Name: [......]
    Position: [......]
    ID/Passport Number: [......]
    Validity period of identity:
    [......]
17. Etc.
    b. copy of tax identification number; 1. Name: [......]
    Tax ID Number:
    [......]
18. Etc.
    c. curriculum vitae and supporting documents
    completed with the latest color passport photo In the event that the Board of Directors and Board of Commissioners are foreign citizens, the photos submitted must meet visa standards and can be processed through biometric applications measuring 4 x 6 cm according to format 3
    Appendix of POJK Number 10/POJK.05/2022;
    Supporting documents in the form of:

1. copy of the latest diploma;
2. copy of expertise certificates (if any);
3. copy of certificate of passing or attendance
   at training previously attended;
4. work history documents in the form of
   recommendation letters and letters of intent to resign from other previous companies for prospective Board of Directors members;
5. awards relevant to the financial industry previously achieved (if any); and
6. skills mastered and proficiency in Indonesian/foreign languages
   d. proof of experience in financial service institutions in the form of recommendation letters or termination letters from financial service institutions; Experience in financial service institutions is:

1. Name: [......]
   Letter Number: [......]
   Financial service institution:
   [......]

1. managerial experience of at least 2 (two)
   years in the fields of credit/financing, risk management, and/or finance for the Board of Directors;
2. operational experience of at least 1 (one)
   year in a financial service institution that conducts business activities based on Sharia Principles for the Board of Directors for Providers that conduct business activities based on Sharia Principles; and
3. experience of at least 2 (two) years at
   the managerial level for the Board of Commissioners Years of experience: [......]

2. Etc.
   e. writing regarding the work plan to be conducted after being appointed to the target position, including:

1. vision and mission;
2. programs to be carried out during the term of office;
   and
3. targets to be achieved during the term of office
   f. statement letter containing the following statements:
4. meets integrity aspects, financial reputation aspects, and is not currently undergoing a process
   Statement letter that has been filled out completely, with sufficient stamp duty, and signed:

1. Mr/Mrs. [......]

assessment of competency and propriety at a financial service institution;
2) is not recorded in the list of non-performing loans and/or
financing;
3) has never been sentenced for committing criminal offenses in the field of financial services and/or
economy based on a court decision that has had permanent legal force within the last 5 (five) years;
4) has never been sentenced for committing criminal offenses based on a court decision that has had permanent legal force within the last 5 (five) years;
5) has never been declared bankrupt or declared guilty causing a business entity
to be declared bankrupt based on a court decision that has had permanent legal force within the last 5 (five) years; and
6) has never been a shareholder,
Board of Directors, Board of Commissioners at a financial service company whose business license was revoked
2. Etc.

for committing violations within the last 5 (five) years For foreign citizens, attach documents equivalent to a certificate of good conduct issued by the original authority of the foreign citizen's country of origin or the foreign legal entity that is legalized by the Embassy of the Republic of Indonesia in the country of origin of the foreign citizen or the foreign legal entity and accompanied by a translation into Indonesian g. proof of residence permit and work permit letter from the competent authority for Board of Directors members with foreign nationality and Board of Commissioners members with foreign nationality who reside in Indonesia; and Name: [......] Position: [......] Permit Number: [......] Date: [......] h. proof of work competence certificate from a professional certification institution in the field of financial technology registered with the Financial Services Authority for the Board of Directors and Board of Commissioners

Additional information (if needed):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Clear Name]

Note:

1. How to fill out: click twice on the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Joint Financing Services.

SELF-ASSESSMENT FORM 7 APPLICATION FOR APPROVAL OF BUSINESS LICENSE RETURN PLAN FORM: 7 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF BUSINESS LICENSE RETURN PLAN Provider Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Application for approval of the business license return plan
   is submitted using format 18
   Appendix of POJK Number 10/POJK.05/2022 and
   signed by the Board of Directors
   Article 78 paragraph (3)
   POJK Number
   10/POJK.05/2022

2. The Provider is not currently subject to sanctions
   of suspension of business activities
   Article 78 paragraph (2)
   POJK Number
   10/POJK.05/2022

3. Documents explaining the reasons for the cessation of operational activities
   Article 78 paragraph (3)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

4. Documents containing a plan for the settlement of users' rights and obligations, which at a minimum contain:

1. procedures for settling users' rights and obligations;
2. procedures for settling disputes arising from the settlement of users' rights and obligations;
   and
3. the timeframe for implementing the settlement of rights
   Article 78 paragraph (3)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

5. Minutes of the Annual General Meeting of Shareholders (AGMS) regarding the plan to cease the Organizer's business activities
   Article 78 paragraph (3)
   letter c of Financial Services Authority Regulation Number 10/POJK.05/2022

6. The latest monthly report
   Article 78 paragraph (3)
   letter d of Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 8 APPLICATION FOR APPROVAL OF LIQUIDATION TEAM MEMBERS FORM: 8 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF LIQUIDATION TEAM MEMBERS Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Application for approval of the formation of liquidation team members is signed by the Board of Directors
   Article 85 paragraph (2)
   Financial Services Authority Regulation Number 10/POJK.05/2022

2. Photocopy of identity proof of prospective liquidation team members
   Article 85 paragraph (3)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

3. Curriculum vitae of prospective liquidation team members
   Article 85 paragraph (3)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

4. Statement from prospective liquidation team members that they are willing to carry out the liquidation
   Article 85 paragraph (3)
   letter c of Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 9 APPLICATION FOR APPROVAL OF EXTENSION OF LIQUIDATION IMPLEMENTATION TIMEFRAME FORM: 9 SELF-ASSESSMENT FORM APPLICATION FOR APPROVAL OF EXTENSION OF LIQUIDATION IMPLEMENTATION TIMEFRAME Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Application for extension of liquidation implementation timeframe:
First extension Liquidation implementation end date:
Second extension 1. Liquidation implementation end date: …Year…
2. End date of the first extension of the liquidation implementation timeframe: ...Year…

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Application for approval of the extension of the liquidation implementation timeframe is signed by the Board of Directors and contains at least:
   a. reasons for the extension of the liquidation implementation timeframe;
   Article 89 paragraph (3)
   Financial Services Authority Regulation Number 10/POJK.05/2022

b. progress report of the liquidation process up to the date of the application along with supporting evidence; and
c. work plan and budget during the extension of the liquidation implementation timeframe

2. The application is submitted at the latest 4 (four) months before the expiration of the liquidation implementation timeframe or the expiration of the first extension
   Article 89 paragraph (4)
   Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 10 REPORTING ON THE DETERMINATION OF CONTROLLING SHAREHOLDERS AND ITS CHANGES FORM: 10 SELF-ASSESSMENT FORM REPORTING ON THE DETERMINATION OF CONTROLLING SHAREHOLDERS AND ITS CHANGES Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :

Permanent controlling shareholders:
No. Name of Controlling Shareholder Number of Shares Nominal Value (Rp) (%) 1. 2. Etc. Total

New controlling shareholders:
Before Changes After Changes

No.
Name of Controlling
Shareholder
Number of
Shares
Nominal Value (Rp) (%) No.
Name of Controlling
Shareholder
Number of
Shares
Nominal Value (Rp) (%)
1.
2.
3.
Total

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting on the determination of controlling shareholders and its changes is submitted using Format 1 of the Appendix of Financial Services Authority Regulation Number 10/POJK.05/2022 and is signed by the Board of Directors
   Article 5 paragraph (4)
   Financial Services Authority Regulation Number 10/POJK.05/2022

2. Controlling shareholders do not become controlling shareholders of more than 1 (one) conventional Organizer or 1 (one) Organizer based on Sharia Principles
   Article 6 paragraph (1) Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 11 REPORTING ON THE IMPLEMENTATION OF THE AGMS THAT APPROVED CONVERSION TO AN ORGANIZER BASED ON SHARIA PRINCIPLES FORM: 11 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF THE AGMS THAT APPROVED CONVERSION TO AN ORGANIZER BASED ON SHARIA PRINCIPLES Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Financial Services Authority approval letter number :
Financial Services Authority approval letter date :

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting on the implementation of the AGMS that approved conversion to an Organizer based on Sharia Principles is signed by the Board of Directors
   Article 13 paragraph (2)
   Financial Services Authority Regulation Number 10/POJK.05/2022

2. Copy of the deed of amendment to the Articles of Association which states:
   a. name of the Organizer based on Sharia Principles; b. the purpose and objectives of the Organizer, namely to conduct business activities based on Sharia Principles; and
   c. the authority and responsibilities of the Sharia Board,
   accompanied by proof of approval, proof of consent, and/or proof of notification receipt from the competent authority
   Article 13 paragraph (2)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

Approval letter number:
[……]
Date: [……]
Consent letter number
Ministry of Law and Human Rights: [……]
Date: [……]
Notification receipt letter number:
[……]
Date: [……]
Competent authority:
[……]

3. Photocopy of the taxpayer identification number (NPWP) in the name of the Organizer based on Sharia Principles resulting from the conversion
   Article 13 paragraph (2)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

4. Copy of the AGMS minutes deed that approved conversion to an Organizer based on Sharia Principles
   Article 13 paragraph (2)
   letter c of Financial Services Authority Regulation Number 10/POJK.05/2022

Number: [……]
Date: [……]
Notary: [……]
Substance: [……]

5. Copy of the AGMS minutes deed stating the appointment of members of the Board of Directors, members of the Board of Commissioners, and/or members of the Sharia Board
   Article 13 paragraph (2)
   letter d of Financial Services Authority Regulation Number 10/POJK.05/2022

6. Proof of appointment of Sharia Board members and proof of approval from the National Sharia Board regarding the appointment of Sharia Board members
   Article 13 paragraph (2)
   letter e of Financial Services Authority Regulation Number 10/POJK.05/2022

7. Approval from the Sharia Board regarding business activities based on Sharia Principles to be marketed, at a minimum covering:
   a. the Organizer's business model; b. calculation of financing economic benefits;
   c. marketing methods; and
   d. examples of Sharia contracts
   Article 13 paragraph (2)
   letter f of Financial Services Authority Regulation Number 10/POJK.05/2022

8. Cooperation agreement for escrow accounts and virtual accounts with commercial banks conducting business activities based on Sharia Principles
   Article 13 paragraph (2)
   letter g of Financial Services Authority Regulation Number 10/POJK.05/2022

9. Copy of the application (specifically for mobile-based Organizers)
   Article 13 paragraph (2)
   letter h of Financial Services Authority Regulation Number 10/POJK.05/2022

10. Electronic copy of all attachment documents of the report
    Article 13 paragraph (2)
    letter i of Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 12 REPORTING ON THE USE OF FOREIGN WORKERS FORM: 12 SELF-ASSESSMENT FORM REPORTING ON THE USE OF FOREIGN WORKERS Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Name of foreign worker :
Duration of employment :
Name of accompanying Indonesian worker :

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES Requirements for the Use of Foreign Workers

1. The duration of foreign worker employment is at most 3 (three) years for one term of office and cannot be extended
   Article 18 paragraph (1)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

2. Foreign workers are employed in the Information Technology field as:
   a. experts with a level one tier below the Board of Directors; or b. consultants
   Article 18 paragraph (1)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

Position of employed foreign worker: [……]

3. Foreign workers meet the requirements:
   a. possess expertise corresponding to the field of duty that will be their responsibility; and
   Article 18 paragraph (2)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

b. meet the provisions of legislation in the field of labor
Article 18 paragraph (2)
letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

Completeness of Documents for Reporting on the Use of Foreign Workers
4. Reporting on the use of foreign workers is submitted using Format 5 of the Appendix of Financial Services Authority Regulation Number 10/POJK.05/2022 and is signed by the Board of Directors
Article 18 paragraph (3)
Financial Services Authority Regulation Number 10/POJK.05/2022

5. Curriculum vitae of the employed foreign workers in accordance with Format 3 of the Appendix of Financial Services Authority Regulation Number 10/POJK.05/2022, accompanied by the latest 4 x 6 cm color passport-sized photo and a photocopy of documents describing the field of expertise
   Article 18 paragraph (3)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

In the event that the shareholder is a foreign citizen, the photo submitted must meet visa standards and can be processed through the biometric application

6. Annual education and training program plan during the employment of the aforementioned foreign workers
   Article 18 paragraph (3)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

Description of the education and training program plan during the employment of foreign workers describing the knowledge, expertise, and technology transfer process, target participants, accompanied by expected results and implementation time

7. Placement plan and field of duty that is the responsibility of foreign workers, including information regarding:
   a. placement b. field of duty along with detailed tasks and responsibilities; and
   c. organizational structure
   Article 18 paragraph (3)
   letter c of Financial Services Authority Regulation Number 10/POJK.05/2022

8. Appointment of at least 1 (one) Indonesian worker as an accompaniment for 1 (one) foreign worker, accompanied by a letter of appointment of the Indonesian worker as an accompaniment
   Article 18 paragraph (4)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

Letter number: [……]
Date: [……]
Indonesian worker name:

1. [……]
2. Etc.

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 13 REPORTING ON THE IMPLEMENTATION OF EDUCATION AND TRAINING PROGRAMS FORM: 13 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF EDUCATION AND TRAINING PROGRAMS Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Name of foreign worker :

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting is submitted by the Board of Directors and is accompanied by a description of the event implementation of the education and training program
   Article 18 paragraph (6)
   Financial Services Authority Regulation Number 10/POJK.05/2022

Event description consists of:

1. Event Name: [......]

2. Implementation Date:
   [......]

3. Implementation Location:
   [......]

4. Event Manager:
   [......]

5. Number of participants: [……]

6. Description of
   event implementation: [……]

7. Description of
   consistency with the program plan, including reasons if implementation does not match the plan and follow-up actions: [……]

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 14 REPORTING ON COOPERATION FORM: 14 SELF-ASSESSMENT FORM REPORTING ON COOPERATION Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Organizer Partner Name :
Type of Cooperation Informative Services
Risk Mitigation Facilitation
Outsourcing

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting is submitted by the Board of Directors
   Article 38 paragraph (3)
   Financial Services Authority Regulation Number 10/POJK.05/2022

2. Proof of registration, license, or equivalent from the Financial Services Authority or other competent authority for the prospective partner
   Article 38 paragraph (2)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

Letter/proof number: [……]
Date of registration or licensing: [……]
Competent authority:
[……]

3. Cooperation agreement
   Article 38 paragraph (2)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

Agreement date: [……]
Institution cooperating:
[……]

4. The cooperation plan has been included in the business plan
   Article 38 paragraph (2)
   letter c of Financial Services Authority Regulation Number 10/POJK.05/2022

Cooperation plan has been included in the business plan for the year: [……]

5. Informative service cooperation is conducted with financial service institutions supervised by the Financial Services Authority
   Article 38 paragraph (4)
   Financial Services Authority Regulation Number 10/POJK.05/2022

Financial service institution:
[……]

6. Implementation of cooperation meets the provisions of legislation
   Article 38 paragraph (5)
   Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 15 REPORTING ON DATA EXCHANGE COOPERATION FORM: 15 SELF-ASSESSMENT FORM REPORTING ON DATA EXCHANGE COOPERATION Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Organizer Partner Name :

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting on data exchange cooperation is submitted using Format 6 of the Appendix of Financial Services Authority Regulation Number 10/POJK.05/2022 and is signed by the Board of Directors
   Article 40 paragraph (5)
   Financial Services Authority Regulation Number 10/POJK.05/2022

2. Business license from the relevant authority when implementing cooperation
   Article 40 paragraph (5)
   Financial Services Authority Regulation Number 10/POJK.05/2022

Letter number: [……]
Letter date: [……]
Relevant authority: [……]

3. Draft data confidentiality agreement which contains at least:
   a. the parties; b. type of data;
   c. data usage and disclosure;
   d. rights and obligations of the parties; e. accountability of the parties; and f. timeframe for data usage and storage.
   Article 40 paragraph (4)
   and paragraph (5) Financial Services Authority Regulation Number 10/POJK.05/2022

Agreement date: [……]
Institution cooperating:
[……]

4. Implementation of cooperation meets the provisions of legislation regarding personal data
   Article 40 paragraph (6)
   Financial Services Authority Regulation Number 10/POJK.05/2022

Additional notes (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and

2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 16 REPORTING ON THE OPENING OF OFFICES OTHER THAN THE HEAD OFFICE FORM: 16 SELF-ASSESSMENT FORM REPORTING ON THE OPENING OF OFFICES OTHER THAN THE HEAD OFFICE Organizer Name :
Letter Number :
Letter Date :
Contact person (name, telephone/mobile, e-mail) :
Purpose and objectives of opening offices other than the head office :
List of opening of offices other than the head office No. City Full Address Person in Charge 1. 2. Etc. *) Address must be written in full, including the village/sub-district name, district, city/regency, and postal code

NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting on the opening of offices other than the head office is submitted using Format 7 of the Appendix of Financial Services Authority Regulation Number 10/POJK.05/2022 and is signed by the Board of Directors
   Article 60 paragraph (5)
   Financial Services Authority Regulation Number 10/POJK.05/2022

2. Offices other than the head office operate using the same Electronic System as the electronic system previously submitted to the Financial Services Authority
   Article 60 paragraph (2)
   Financial Services Authority Regulation Number 10/POJK.05/2022

3. The plan to open offices other than the head office has been included in the business plan
   Article 60 paragraph (4)
   Financial Services Authority Regulation Number 10/POJK.05/2022

The plan to open offices other than the head office has been included in the business plan for the year: [……]

4. Documents describing the office name and function
   Article 60 paragraph (5)
   letter a of Financial Services Authority Regulation Number 10/POJK.05/2022

Office name: [……]
Office function: [……]
Work plan: [……]

5. Domicile certificate from the competent authority or equivalent document
   Article 60 paragraph (5)
   letter b of Financial Services Authority Regulation Number 10/POJK.05/2022

Letter number: [……]
Letter date: [……]
Competent authority:
[……]

6. Proof of ownership or control of offices other than the head office
   Article 60 paragraph (5)
   letter c of Financial Services Authority Regulation Number 10/POJK.05/2022

The aforementioned document can be in the form of a lease contract or other evidence that can show ownership of the office building Office ownership proof/letter Number: [……] Date: [……] Address: [……]

7. Documents describing the name of the office manager, description of duties, and authority of the office manager, accompanied by:
   Article 60 paragraph (5)
   letter d of Financial Services Authority Regulation Number 10/POJK.05/2022

a. photocopy of identity documents in the form of a valid identity card or passport; Name: [……] ID/Passport Number: [……] Validity period of identity: [……]

b. photocopy of the taxpayer identification number (NPWP) for Indonesian citizens or equivalent documents valid for foreign citizens; and Name: [……] NPWP Number: [……]

c. curriculum vitae accompanied by the latest 4 x 6 cm color passport-sized photo supported by documents:

1. photocopy of the highest diploma;
2. photocopy of expertise certificates (if any);
3. photocopy of certificates of passing or attendance of training previously attended;
4. work history documents;
5. awards relevant to the financial industry previously achieved (if any); and
6. skills mastered and proficiency in Indonesian/foreign languages

8. Proof of inclusion of the global positioning system (GPS) address of offices other than the head office on the Electronic System website
   Article 60 paragraph (5)
   letter e of Financial Services Authority Regulation Number 10/POJK.05/2022

9. Proof of the letter of appointment of the manager of offices other than the head office
   Article 60 paragraph (5)
   letter f of Financial Services Authority Regulation Number 10/POJK.05/2022

Letter number: [……]
Date: [……]

10. Board of Directors decision letter regarding the opening of offices other than the head office
    Article 60 paragraph (5)
    letter g POJK
    Letter number: [……]
    Letter date: [……]
    Additional information (if necessary):
    We, the undersigned, declare that:
11. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
12. The documents submitted online are true and identical to the original documents.
    (City)[……], (Date)[……]
    Board of Directors [………………..] signature
    [Full Name]
    Note:
13. How to fill in: double-click in the box, then select “Checked”.
14. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 17 REPORTING ON THE CESSATION OR CLOSURE OF OFFICES OTHER THAN THE HEAD OFFICE FORM: 17 SELF-ASSESSMENT FORM REPORTING ON THE CESSATION OR CLOSURE OF OFFICES OTHER THAN THE HEAD OFFICE Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Purpose and objective of closing offices other than the head office :
List of closure of offices other than the head office No. City Full Address Person in Charge 1. 2. Etc. *) Address must be written in full, including the name of the village/sub-district, district, city/regency, and postal code NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Reporting on the cessation or closure of offices other than the head office is submitted using format 8 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 61 paragraph (4)
   POJK Number
   10/POJK.05/2022

2. The plan for the cessation or closure of offices other than the head office has been included in the business plan
   Article 61 paragraph (2)
   POJK Number
   10/POJK.05/2022
   The plan for the cessation or closure of offices other than the head office has been included in the business plan year:
   [……]

3. Cover letter containing reasons for closing offices other than the head office
   Article 61 paragraph (4)
   letter a POJK
   Number
   10/POJK.05/2022
   Letter number: [……]
   Letter date: [……]
   Reason for closure: [……]

4. Proof of submission of announcement of closure of offices other than the head office through the Electronic System to users
   Article 61 paragraph (4)
   letter b POJK
   Number
   10/POJK.05/2022
   Proof of announcement of closure of offices other than the head office can be in the form of screenshots of the announcement publication on the website and/or mobile application

5. Proof of submission of transfer of services from offices other than the head office that are closed to the head office or the nearest office other than the head office
   Article 61 paragraph (4)
   letter c POJK
   Number
   10/POJK.05/2022
   Proof of transfer of services from offices other than the head office can be in the form of screenshots of the announcement publication on the website and/or mobile application Additional information (if necessary):
   We, the undersigned, declare that:

6. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and

7. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:

8. How to fill in: double-click in the box, then select “Checked”.

9. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 18 REPORTING ON THE IMPLEMENTATION OF THE CHANGE OF SERVICE PROVIDER NAME AND/OR ELECTRONIC SYSTEM FORM: 18 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF CHANGE OF SERVICE PROVIDER NAME AND/OR ELECTRONIC SYSTEM Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Brief description regarding the background of the name change :
Implementation of name change realization
No. Letter Number and Date of Business License/ Electronic System Number *) Old Name New Name 1.

Etc.
*) Strike out what is not necessary
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the implementation of the change of Service Provider name and/or electronic system is submitted using format 9 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 62 paragraph (3)
   POJK Number
   10/POJK.05/2022
2. The plan for the change of name and/or electronic system has been included in the business plan
   Article 62 paragraph (2)
   POJK Number
   10/POJK.05/2022
   The plan for the change of name and/or Electronic System has been included in the business plan year: [……]
3. Letter of receipt of notification or approval from the competent authority
   Article 62 paragraph (4)
   POJK Number
   10/POJK.05/2022
   Letter number: [……]
   Letter date: [……]
   Competent authority:
   [……]
   Additional information (if necessary):

We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. How to fill in: double-click in the box, then select “Checked”.
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 19 REPORTING ON THE CHANGE OF HEAD OFFICE AND OFFICES OTHER THAN THE HEAD OFFICE ADDRESS FORM: 19 SELF-ASSESSMENT FORM REPORTING ON THE CHANGE OF ADDRESS OF HEAD OFFICE AND OFFICES OTHER THAN THE HEAD OFFICE Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Purpose and objective of address change :
List of address changes
No. Office Name Address *) and Old Phone Number Office Registration Number and Date for Offices Other Than the Head Office Address *) and New Phone Number Effective Date of Office Address Change 1. 2. Etc. *) Address must be written in full, including the name of the village/sub-district, district, city/regency, and postal code

NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the change of address of the head office and offices other than the head office is submitted using format 10 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 63 paragraph (3)
   POJK Number
   10/POJK.05/2022
2. The plan for the change of address of the head office and offices other than the head office has been included in the business plan
   Article 63 paragraph (2)
   POJK Number
   10/POJK.05/2022
   The plan for the change of address of the head office and offices other than the head office has been included in the business plan year: [……]
3. Data regarding the office address accompanied by supporting documents from the competent authority which at least states the name and address of the Service Provider
   Article 63 paragraph (3)
   letter a POJK
   Number
   10/POJK.05/2022
4. Proof of ownership or control of the office building showing the Service Provider's office address along with photos of the building's exterior and interior and room layout
   Article 63 paragraph (3)
   letter b POJK
   Number
   10/POJK.05/2022
   Can be in the form of ownership certificates, use right certificates, copies of notarial deeds for building lease contracts, land and building tax in the owner's name, or other proof showing ownership or control
5. Proof of inclusion of global positioning system (GPS) address of the head office and offices other than the head office on the Electronic System page
   Article 63 paragraph (3)
   letter c POJK
   Number
   10/POJK.05/2022
   Additional information (if necessary):
   We, the undersigned, declare that:
6. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
7. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill in: double-click in the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 20 REPORTING ON THE CHANGE OF BUSINESS MODEL FORM: 20 SELF-ASSESSMENT FORM REPORTING ON THE CHANGE OF BUSINESS MODEL Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Purpose and objective of business model change :
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the change of business model is submitted using format 11 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 64 paragraph (3)
   POJK Number
   10/POJK.05/2022

2. The plan for the change of business model has been included in the business plan
   Article 63 paragraph (2)
   POJK Number
   10/POJK.05/2022
   The plan for the change of business model has been included in the business plan year: [……]

3. Business feasibility study at least contains:
   a. explanation of the business model; and b. 3 (three) years or more of funding projections
   Article 64 paragraph (3)
   letter a POJK
   Number
   10/POJK.05/2022
   Business model: [……]
   Funding projections: [……]

4. Cost-benefit analysis Article 64 paragraph (3)
   letter b POJK
   Number
   10/POJK.05/2022

5. Risk analysis and mitigation Article 64 paragraph (3)
   letter c POJK
   Number
   10/POJK.05/2022

6. Cooperation agreements with other parties (if any) Article 64 paragraph (3)
   letter d POJK
   Number
   10/POJK.05/2022
   Additional information (if necessary):

We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. How to fill in: double-click in the box, then select “Checked”.
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 21 REPORTING ON THE REALIZATION OF PAID-UP CAPITAL INCREASE FORM: 21 SELF-ASSESSMENT FORM REPORTING ON THE REALIZATION OF PAID-UP CAPITAL INCREASE Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Letter number of Financial Services Authority approval for paid-up capital increase :
Date of Financial Services Authority approval letter for paid-up capital increase :
Form of addition of paid-up capital cash deposit transfer of retained earnings dividend shares

Composition of ownership change:
Before Change After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%) Total 100 Total 100 NO. DESCRIPTION LEGAL BASIS COMPLETENESS YES NO NOTES

1. Deed of Change Article 70 paragraph (4)
   POJK Number
   10/POJK.05/2022
   Deed number: [……]
   Date: [……]
   Notary: [……]
2. Proof of approval from competent authority Article 70 paragraph (4)
   POJK Number
   10/POJK.05/2022
   Letter number: [……]
   Letter date: [……]
   Competent authority:
   [……]
   Additional information (if necessary):

We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. How to fill in: double-click in the box, then select “Checked”.
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 22 REPORTING ON THE IMPLEMENTATION OF THE GMS THAT APPROVED THE CHANGE OF OWNERSHIP FORM: 22 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF THE GMS THAT APPROVED THE CHANGE OF OWNERSHIP Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Letter number of Financial Services Authority approval for the change of ownership plan :
Date of Financial Services Authority approval letter for the change of ownership plan :
Composition of ownership change:
Before Change After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%)

Total 100 Total 100
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the implementation of the GMS that approved the change of ownership is submitted using format 16 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 75 paragraph (2)
   POJK Number
   10/POJK.05/2022
2. Copy of the GMS minutes deed that approved the change of ownership
   Article 75 paragraph (2)
   letter a POJK
   Number
   10/POJK.05/2022
   Deed number: [……]
   Date: [……]
   Notary: [……]
   Substance: [……]
3. Copy of the deed of change of ownership Article 75 paragraph (2)
   letter b POJK
   Number
   10/POJK.05/2022
   Deed number: [……]
   Date: [……]
   Notary: [……]

Substance: [……]
4. Latest draft of the articles of association resulting from the change of ownership
Article 75 paragraph (2)
letter c POJK
Number
10/POJK.05/2022
Approval proof number
Ministry of Law and Human Rights: [……]
Date: [……]
Substance: [……]
5. Document stating that the Service Provider has no tax debts from the competent authority
Article 75 paragraph (2)
letter d POJK
Number
10/POJK.05/2022
Number: [.........]
Date:[.........]
Signed by: [.........]
6. Proof of announcement of change of ownership Article 75 paragraph (2)
letter e POJK
Number
10/POJK.05/2022
Announcement to the public can be done through newspapers or print media and electronic media or the Service Provider's website Additional information (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. How to fill in: double-click in the box, then select “Checked”.
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 23 REPORTING ON THE IMPLEMENTATION OF THE GMS THAT APPROVED MERGER OR CONSOLIDATION FORM: 23 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF THE GMS THAT APPROVED MERGER OR CONSOLIDATION Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Letter number of Financial Services Authority approval for the Merger or Consolidation plan :
Date of Financial Services Authority approval letter for the Merger or Consolidation plan :
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the implementation of the GMS that approved
   Merger or Consolidation is submitted using format 16 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 75 paragraph (2)
   POJK Number

10/POJK.05/2022
2. Copy of the GMS minutes deed that approved
Merger or Consolidation
Article 75 paragraph (2)
letter a POJK
Number
10/POJK.05/2022
Deed number: [……]
Date: [……]
Notary: [……]
Substance: [……]
3. Copy of the deed of change of Merger or
Consolidation
Article 75 paragraph (2)
letter b POJK
Number
10/POJK.05/2022
Deed number: [……]
Date: [……]
Notary: [……]
Substance: [……]
4. Latest draft of the articles of association resulting from
Merger or Consolidation
Article 75 paragraph (2)
letter c POJK
Number
10/POJK.05/2022

5. Document stating that the Service Provider has no tax debts from the competent authority
   Article 75 paragraph (2)
   letter d POJK
   Number
   10/POJK.05/2022
   Number: [……]
   Date: [……]
   Signed by: [……]
6. Proof of announcement of Merger or Consolidation Article 75 paragraph (2)
   letter e POJK
   Number
   10/POJK.05/2022
   Announcement to the public can be done through newspapers or print media and electronic media or the Service Provider's website Additional information (if necessary):
   We, the undersigned, declare that:
7. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
8. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature

[Full Name]
Note:

1. How to fill in: double-click in the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 24 REPORTING ON THE IMPLEMENTATION OF CHANGE OF OWNERSHIP FORM: 24 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF CHANGE OF OWNERSHIP Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Letter number of Financial Services Authority approval for the change of ownership plan :
Date of Financial Services Authority approval letter for the change of ownership plan :
Composition of ownership change:
Before Change After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%)

Total 100 Total 100
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the implementation of change of ownership
   is submitted using format 17 of the Appendix to POJK Number 10/POJK.05/2022 and signed by the Board of Directors
   Article 76 POJK
   Number
   10/POJK.05/2022
2. Copy of the establishment deed or articles of association that
   have been approved, approved by, or notified to the competent authority
   Article 76 POJK
   Number
   10/POJK.05/2022
   Deed number: [……]
   Date: [……]
   Notary: [……]
   Substance: [……]
   Ministry of Law and Human Rights approval/ approval/notification number:
   [.......]

Date: [.......]
3. Change of ownership is caused by the entry of new shareholders through the transfer of shares from existing shareholders (proven by the realization of Article 69 paragraph (1) letter n POJK Number 10/POJK.05/2022):
Article 69 paragraph (1)
letter n POJK
Number
10/POJK.05/2022 a. Copy of the sale and purchase deed/deed of transfer of rights over shares; Number: [……] Date: [……] Notary: [……] Substance: [……] b. Photocopy of payment proof from the buyer to the seller Sender name: [……] Receiver name: [……] Sender bank name: [……] Receiver bank name: [……]

Transaction date: [……]
Transfer amount: [……]
4. Change of ownership is caused by the issuance of new shares for existing shareholders or new shareholders (proven by the realization of Article 69 paragraph (1) letter n POJK Number 10/POJK.05/2022):
Article 69 paragraph (1)
letter n POJK
Number
10/POJK.05/2022 a. proof of transfer of funds to the Service Provider's account which has been legalized by the bank; Transaction date:
[……]
Bank name: [……]
Account number: [……]
Account owner name:
[……]
Receiving bank: [……]
Receiving account number:
[……]

Receiver name:
[……]
Amount of fund transfer:
Rp [……]
Date received: [……] b. photocopy of the Service Provider's bank statement showing incoming funds equivalent to the paid-up capital increase which has been legalized by the bank; and Account owner name:
[……]
Account number: [……]
Bank name: [……]
Bank statement period:
[……] to [……]
Date legalized by bank:
[……]

c. Service Provider's financial report after the paid-up capital increase signed by the Board of Directors
Financial report month:
[……]
5. Attachment of supporting documents showing that the funds used by shareholders to make capital participation come from escrow accounts and/or time deposits submitted during the approval process, consisting of:
Article 69 paragraph (1)
letter m POJK
Number
10/POJK.05/2022 a. proof of withdrawal of balance in the fund placement account (escrow account/time deposit) which has been legalized by the bank; Transaction date: [……] Bank name: [……] Account number: [……] Account owner name: [……] b. photocopy of bank statement showing incoming funds from time deposit withdrawal Account owner name:
[……]
Bank name: [……]
Account number: [……]

Additional information (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services; and
2. The documents submitted online are true and identical to the original documents.
   (City)[……], (Date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. How to fill in: double-click in the box, then select “Checked”.
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Joint Financing Services.

FORM SELF-ASSESSMENT 25 REPORTING ON THE IMPLEMENTATION OF MERGER OR CONSOLIDATION FORM: 25 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF MERGER OR CONSOLIDATION Service Provider Name :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
Letter number of Financial Services Authority approval for the merger or consolidation plan :
Date of Financial Services Authority approval letter for the Merger or Consolidation plan :
Effective Date of Merger or Consolidation :
Before Change After Change
Shareholder Name Total Share Value (Rp) (%) Shareholder Name Total Share Value (Rp) (%)

Total 100 Total 100
Before Change After Change
Position Name Position Name
Board of Directors Board of Directors
….. …..
…… ……
Commissioners Commissioners
….. …..
…… ……
Sharia Supervisory Board Sharia Supervisory Board ….. …..
…… ……
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the implementation of Merger or
   Consolidation is submitted using format
   Article 76 POJK
   Number
   10/POJK.05/2022

---

17 Appendix of POJK Number 10/POJK.05/2022 and signed by the Board of Directors
2. A copy of the deed of establishment or articles of association that
has been approved, agreed to, or notified to the competent authority
Article 76 POJK
Number
10/POJK.05/2022
Deed number: [……]
Date: [……]
Notary: [……]
Substance: [……]
Approval/Agreement/Notification Number
Ministry of Law and Human Rights:
[.......]
Date: [.......]
Additional information (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and

2. The documents submitted online are true and identical to the original documents.
   (city)[……], (date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:

3. How to fill out: double-click in the box, then select “Checked”.

4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 26 REPORTING ON THE COMPLETION OF RIGHTS AND OBLIGATIONS FORM: 26 SELF-ASSESSMENT FORM REPORTING ON THE IMPLEMENTATION OF THE COMPLETION OF RIGHTS AND OBLIGATIONS Name of Service Provider :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the implementation of the completion of rights and
   obligations of the Service Provider to all users signed by the Board of Directors which at least contains:
   a. implementation of the cessation of business activities of the Service Provider; b. implementation of announcements;
   Article 79 paragraph (1) in conjunction with
   Article 82 paragraph (1)
   POJK Number
   10/POJK.05/2022

c. implementation of the settlement of obligations
of the Service Provider to all users; d. the final financial position report of the Service Provider that has been audited by a public accountant; and e. a statement letter from shareholders stating that all obligations of the Service Provider have been settled and if there are claims in the future, they become the responsibility of the shareholders Additional information (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (city)[……], (date)[……]
   Board of Directors [………………..] signature

[Full Name]
Note:

1. How to fill out: double-click in the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 27 REPORTING ON THE REALIZATION OF THE WORK PLAN AND BUDGET FOR LIQUIDATION IMPLEMENTATION FORM: 27 SELF-ASSESSMENT FORM REPORTING ON THE REALIZATION OF THE WORK PLAN AND BUDGET FOR LIQUIDATION IMPLEMENTATION Name of Service Provider :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the realization of the work plan and budget for
   liquidation implementation signed by the Board of Directors which at least contains:
   a. progress of liquidation activities; b. obstacles to not achieving targets;
   c. cash flow report;
   Article 91 paragraph (1)
   POJK Number
   10/POJK.05/2022

d. position of assets that have been liquidated and obligations that have been settled; e. details of budget realization; and f. obstacles faced and follow-up plans Additional information (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (city)[……], (date)[……]
   Board of Directors [………………..] signature
   [Full Name]
   Note:
3. How to fill out: double-click in the box, then select “Checked”
4. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Crowdfunding Services.

SELF-ASSESSMENT FORM 28 REPORTING ON BANKRUPTCY PROCESS FORM: 28 SELF-ASSESSMENT FORM REPORTING ON BANKRUPTCY PROCESS Name of Service Provider :
Letter number :
Letter date :
Contact person (name, telephone/mobile, e-mail) :
NO. DESCRIPTION LEGAL BASIS
COMPLETENESS
YES NO NOTES

1. Reporting on the bankruptcy process is submitted using
   Format 19 Appendix of POJK Number
   10/POJK.05/2022 and signed by the Board of Directors
   Article 94 paragraph (2)
   POJK Number
   10/POJK.05/2022
2. Name of the party filing for bankruptcy Article 94 paragraph (2)
   letter a POJK Number
   10/POJK.05/2022
3. Summary of the bankruptcy declaration petition that
   includes:
   Article 94 paragraph (2)
   letter b POJK Number
   10/POJK.05/2022

a. legal standing of the petitioner which contains a clear description of the petitioner's right to file the petition; and b. reasons for the bankruptcy declaration petition are described clearly and in detail
4. Follow-up plan to be taken by the Service Provider
to follow up on the bankruptcy process
Article 94 paragraph (2)
letter c POJK Number
10/POJK.05/2022
Additional information (if necessary):
We, the undersigned, declare that:

1. The Self-Assessment Form above has been filled out in accordance with the actual situation and has been completed with documents
   as referred to in the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning Information Technology-Based Crowdfunding Services; and
2. The documents submitted online are true and identical to the original documents.
   (city)[……], (date)[……]
   Board of Directors [………………..] signature
   [Full Name]

Note:

1. How to fill out: double-click in the box, then select “Checked”.
2. This Self-Assessment Form is prepared based on the provisions of the Financial Services Authority Regulation Number 10/POJK.05/2022 concerning
   Information Technology-Based Crowdfunding Services.

This copy is in accordance with the original Director of Law 1 Legal Department signed Mufli Asmawidjaja Established in Jakarta on November 25, 2022 EXECUTIVE HEAD OF INSURANCE SUPERVISOR, PENSION FUNDS, FINANCING INSTITUTIONS, AND OTHER FINANCIAL SERVICE INSTITUTIONS FINANCIAL SERVICES AUTHORITY REPUBLIC OF INDONESIA, signed OGI PRASTOMIYONO