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20260331_EDGE_Pemanggilan RUPS_32056314_lamp9.pdf
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Page 1
SURAT PERNYATAAN PEMEGANG SAHAM INDEPENDEN
(PERSEORANGAN)
Yang bertanda tangan dibawah ini:
Nama (1) : _____________________
No. Kartu Identitas : _____________________
Alamat : _____________________
Nomor telepon/HP : _____________________
Dalam hal ini bertindak sebagai pemegang/pemilik sah dari ________________________ (2) Saham di PT
INDOINTERNET TBK (“Perseroan”), dengan ini menyatakan bahwa saya adalah Pemegang Saham Independen
(3)
Perseroan yang tercatat dalam Daftar Pemegang Saham Perseroan pada tanggal 30 Maret 2026.
Apabila di kemudian hari terbukti bahwa pernyataan ini tidak benar, maka saya dapat dikenakan sanksi sesuai
dengan peraturan perundang-undangan yang berlaku.
Tanggal __________________ (4)
[materai Rp10.000]
______________________
__________________ (5)
Petunjuk Pengisian:
(1) Isi nama, nomor kartu identitas dan alamat pihak yang menandatangani Surat Pernyataan.
(2) Sebutkan jumlah seluruh Saham yang dimiliki.
(3) Berdasarkan Peraturan Otoritas Jasa Keuangan Nomor 15/POJK.04/2020 tentang Rencana dan
Penyelenggaraan Rapat Umum Pemegang Saham Perusahaan Terbuka, Pemegang Saham Independen
adalah Pemegang saham yang tidak mempunyai kepentingan ekonomis pribadi sehubungan dengan
suatu transaksi tertentu dan: (a) bukan merupakan anggota direksi, anggota dewan komisaris,
pemegang saham utama, dan pengendali; atau (b) bukan merupakan Afiliasi dari anggota direksi,
anggota dewan komisaris, pemegang saham utama, dan pengendali.
(4) Isi tanggal surat pernyataan ditandatangani.
(5) Isi nama pihak yang menandatangani Surat Pernyataan
(6) Surat Pernyataan wajib ditandatangani dan dibubuhi meterai sesuai dengan ketentuan peraturan
perundang-undangan yang berlaku. Dalam hal dokumen ditandatangani di luar wilayah Republik
Indonesia, dokumen tersebut wajib dilegalisasi atau dilengkapi dengan Apostille sesuai dengan
ketentuan yang berlaku.
Page 2
STATEMENT LETTER OF INDEPENDENT SHAREHOLDERS
(INDIVIDUAL)
The Undersigned:
Name (1) : _____________________
Identity Card No. : _____________________
Address : _____________________
Telephone/Mobile Number : _____________________
Acting as the holder/rightful owner of ________________________ (2) Shares in PT INDOINTERNET TBK
(“Company”); hereby declare that I am Independent Shareholders (3) of the Company that was recorded in
Shareholder Registry as of 30 March 2026.
If in the future this statement is proven to be untrue, I may be subject to any sanction in accordance with the
applicable laws.
Date __________________ (4)
[stamp duty Rp10.000]
______________________
___________________ (5)
Guidelines:
(1) Fill in the name, identity card number and address of the party who signed the Statement Letter.
(2) Indicate the total number of Shares owned.
(3) Based on Financial Services Authority Regulation Number 15/POJK.04/2020 on the Plan and
Implementation of the General Meeting of Shareholders of Public Companies, Independent
Shareholders are shareholders who have no personal economic interest in connection with a particular
transaction and: (a) is not a member of the board of directors, member of the board of commissioners,
principal shareholder and controlling shareholder; or (b) is not an Affiliate of the members of the board
of directors, members of the board of commissioners, principal shareholder and controlling
shareholder.
(4) Fill the date the Statement Letter signed
(5) Fill the party who signed the Statement Letter
(6) The Statement Letter must be duly signed and affixed with a stamp duty in accordance with the
prevailing laws and regulations. If the document is executed outside the territory of the Republic of
Indonesia, it must be legalized or provided with an Apostille in accordance with the applicable
regulations.
Names mentioned 3 people and organisations named in the text · linked when the evidence is strong
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Financial Services Authority
p.2
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