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20250425_HITS_Pemanggilan RUPS_31878296_lamp7.pdf
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SURAT PERNYATAAN PEMEGANG STATEMENT LETTER OF
SAHAM INDEPENDEN INDEPENDENT SHAREHOLDERS OF
PT HUMPUSS INTERMODA PT HUMPUSS INTERMODA
TRANSPORTASI Tbk. TRANSPORTASI Tbk.
Yang bertanda tangan di bawah ini: The undersigned :
Nama Pemegang Saham/ :
Name of Shareholder
Alamat/Address :
(Selanjutnya disebut “Pemegang Saham”/hereinafter referred to as the “Shareholder”).
Dalam hal ini diwakili oleh/in this case represented by:
1. Nama/Name :
Alamat/Address :
Jabatan/Tittle :
2. Nama/Name :
Alamat/Address :
Jabatan/Tittle :
Selaku Pemegang Saham dari: As the Shareholder of:
saham/shares
dalam PT Humpuss Intermoda Transportasi in the PT Humpuss Intermoda Transportasi
Tbk. (“Perseroan”) yang terdaftar dalam Tbk. (the “Company”) registered in the
Daftar Pemegang Saham Perseroan tanggal Register of Shareholders of the Company
24 April 2025, dengan ini menyatakan dated 24 April 2025, hereby state that in
bahwa sehubungan dengan Rencana accordance with the Company’s Proposed
Transaksi Perseroan sebagaimana Transaction as described in the Information
diuraikan dalam Keterbukaan Informasi Disclosure to the Shareholders and Meeting
Kepada Pemegang Saham dan mata acara agenda as described in the Invitation of
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Rapat sebagaimana diuraikan dalam Extraordinary General Meetings of
Pemanggilan Rapat Umum Pemegang Shareholders published in eASY.KSEI
Saham Luar Biasa yang diumumkan melalui facility, website of PT Bursa Efek Indonesia
fasilitas eASY.KSEI, situs web PT Bursa and website of the Company
Efek Indonesia dan situs web Perseroan (https://www.hits.co.id/) respectively dated
(https://www.hits.co.id/) masing-masing 10 April 2025 and 25 April 2025, declare
pada tanggal 10 April 2025 dan 25 April truthfully that:
2025, menyatakan dengan sesungguhnya
bahwa:
1. Saya/kami merupakan Pemegang 1. I am/we are Independent
Saham Independen yang: (i) bukan Shareholders(s) who: (i) are not
merupakan anggota Direksi, anggota member of the Board of Director or
Dewan Komisaris, Pemegang Saham member of the Board of Commissioners
Utama dan Pengendali (sebagaimana of the Company, Pricipal Shareholders
didefinisikan dalam Peraturan Otoritas and Controller (as defined under
Jasa Keuangan Nomor Financial Services Authority Regulation
15/POJK.04/2020 tentang Rencana Number 15/POJK.04/2020 concerning
Penyelenggaraan Rapat Umum the Plan to Organize the General
Pemegang Saham Perusahaan Meeting of Shareholders of a Publicly
Terbuka atau bukan merupakan afiliasi Listed Company), or are not affiliated
dari Pengendali, pemegang saham with the Controller, principal
utama, anggota Direksi atau anggota shareholders, member of the Board of
Dewan Komisaris Perseroan; atau (ii) Director or member of the Board of
tidak memiliki kepentingan ekonomis Commissioners of the Company; or (ii)
pribadi atas Rencana Transaksi yang do not have personal economic interest
dimintakan persetujuan Pemegang in the Proposed Transaction that will be
Saham Independen melalui Rapat requested for approval from the
Umum Pemegang Saham Perseroan Independent Shareholders in the
tanggal 21 Mei 2025 sesuai ketentuan General Meeting of Shareholders of the
peraturan di bidang pasar modal. Company dated 21 May 2025 in
accordance to capital market law.
2. Apabila dikemudian hari terbukti bahwa 2. If in the future it is proven that the above
pernyataan tersebut di atas tidak benar, statements are not true,
maka saya/kami bersedia dikenakan I am/we are willing to be imposed by
sanksi sesuai dengan peraturan sanctions in accordance with the
perundang-undangan yang berlaku. applicable laws and regulations.
Demikian pernyataan ini dibuat dengan Thus this statement is made truthfully for the
sebenar-benarnya untuk keperluan purposes of the decision making on the
pengambilan keputusan atas nama mata proposed agenda as referred.
acara terkait rencana Transaksi Perseroan
sebagaimana dimaksud.
Ditandatangani di/Executed in
Pada tanggal/dated
Yang menyatakan/The undersigned,
Stamp duty
Rp10,000
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Nama/Name :
NOTE / PERHATIAN
Surat Pernyataan ini harus direkatkan This Statement Letter shall be affixed with
meterai Rp.10.000,- dan sebagian tanda stamp duty of Rp.10.000,- and part of the
tangan pemberi pernyataan harus mengenai undersigned’s signature shall be affixed on
meterai tersebut yang telah diberi tanggal. said stamp duty duly dated.
Names mentioned 5 people and organisations named in the text · linked when the evidence is strong
unresolved
org
TRANSPORTASI Tbk.
p.1
unresolved
org
Financial Services Authority
p.2
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