Remittance Form

FORMULIR PENGIRIMAN UANG

REMITTANCE FORM

Nomor BNI Remittance Card

:

BNI Remittance Card number

Nama penerima uang

:

Beneficiary name

Hubungan dengan penerima uang

:

Relationship with the beneficiary

Bank penerima uang (sertakan informasi cabang jika ada)

:

Beneficiary bank (include branch information if available)

Nomor rekening bank penerima uang

:

Beneficiary bank account number

Sumber dana

:

Source of funds

Tujuan penggunaan dana

:

Purpose of funds

Jumlah pengiriman

:

Remittance amount

Biaya pengiriman*

:

Service charge*

Nilai cek dalam US Dollar

:

Check amount in US Dollar

*Biaya Pengiriman/Service Charge:

USD 1-300

USD 10

USD 301 - 2,000

USD 20

USD 2,001 - 50,000

USD 30

USD 50,001 ke atas / and above

USD 40

In line with the Dodd-Frank Wall Street Reform and Consumer Protection Act date of implementation effective February 7, 2013, we the bank PT. Bank Negara Indonesia (Persero) New

York Agency, is required to provide a disclosure to a consumer before the consumer pays for a remittance transfer, the following information:

(a) The exchange rate, which in the case of check-mailing will be given when we receive the check; (b) BNI Fees; (c) Amount of money to be delivered abroad, which in the case of check-mailing will be

given when BNI receives the check; (d) Receipt – which is the copy of the Remittance Form and, in the case of check-mailing, additional receipt would also be given when BNI receives the check (e)

Tentative date the wire transfer will be paid at destination, which in the case of check-mailing will be given when BNI receives the check; (f) Other banks fee: the other Bank (not-BNI) may deduct their

fees.

Cancellation Rights: The ordering consumer has the right to cancel a wire transfer application within 30 minutes of the application of wire transfer. Consumer can get their money back if they cancel

within the allowed time. BNI requires a written request to cancel signed by the applicant.

Error Resolution: Within 180 days from the date of application you have a right to dispute errors in your wire transfer. If you think there is an error on the part of the bank (BNI) of transmitting the

wire transfer, i.e., wrong amount, sent to wrongful beneficiary, the bank (BNI) will investigate the error and we will correct the error promptly within 3 business days with a written explanation.

Dengan membubuhkan tanda tangan di bawah ini:

(i.) Saya menyatakan bahwa semua pernyataan dan informasi yang saya berikan dalam dokumen ini adalah benar, lengkap dan akurat sejauh sepengetahuan saya, dan dilandasi dengan niat

baik; dan

(ii.) Saya setuju untuk tunduk pada seluruh ketentuan pengiriman uang yang ditetapkan oleh PT. Bank Negara Indonesia (Persero) Tbk. ("BNI") saat ini maupun yang ditetapkan oleh BNI di

kemudian hari.

By providing my signature below:

(i.) I certify that all statements and information furnished in this document are true, complete and accurate to the best of my knowledge, and are made in good faith; and

(ii.) I agree to the all remittance terms and conditions currently set by PT. Bank Negara Indonesia (Persero) Tbk. ("BNI") and set by BNI in the future time.

Tanda Tangan / Signature

PT. Bank Negara Indonesia (Persero), Tbk.

New York Agency

th

55 Broadway, 5

Floor

New York, NY 10006

Phone: 212-943-4750 Ext. 601

For questions or complaints, contact:

New York State Department of Financial Services | 1-877-BANKS-NYS (1-877-226-5697) |

Consumer Financial Protection Bureau | 855-411-2373 |855-729-2372 (TTY/TDD) |