KEMENTERIAN KEUANGAN REPUBLIK INDONESIA Speciat

KEMENTERIAN KEUANGAN REPUBLIK INDONESIA
DIREKTORAT J ENDERAL PENGELOLAAN UTANG
DIREKTORAT PINJAMAN DAN HIBAH
GEDUNG FRANS SEDA LANTAI 6, JALAN GUNUNG SAHARI RAYA NO. 4 JAKARTA 10710
TELEPON (021 ) 3458289, 3865330, PSW' 2602; FAKSIMI LE (O21) 3447386; SITUS *l'#".drilc c' 'c
Nomor
Lampiran
Hal
l5 November 2013
S- tltoo |PU.212013
1 (satu) dokumen
Penyampaian IDB Disbursement Applications Forms
Yth.
(Daftar Terlampir)
Sehubungan dengan surat Acting Director IDB Regional Office Kuala Lumpur
ref:93/156/13 tanggal 29 Oktober 2013 perihal "lDB Prescribed Forms for Disbursement
Applications" (copy terlampir), dengan ini kami sampaikan IDB Disbursement Applications
dimaksud untuk dapat dijadikan format standar dalam pelaksanaan transaksi permintaan
disbursemenf pinjaman luar negeri bersumber dari IDB yang menurut hemat karni perlu mendapat
perhatian Saudara.
Dapat disampaikan bahwa penggunaan Drsbursement Applications Forms dimaksud dapat
mengikuti format sebagai berikut:
a. Untuk disbursement
b.
menggunakan mekanisme Direct Payment, Reimbursement dan
Speciat Account menggunakan "Form A: Disbursenent Application Form" dan
"Form C: Summary Statement".
Untuk disbursemenf menggunakan mekanisme Letters of Credit menggunakan Form B dan
Form C.
Demikian disampaikan, atas perhatian dan kerjasama yang baik diucapkan terima kasih.
Sukbrini
196706221992022001
'..?
Lampiran Surat
Nomor
: S- rllc, tPu.2l2o13
Tanggal : 1( November2O13
Kepada Yth.
1.
Kepala Departemen Pengelolaan Pinjaman dan Transaksi Pemerintah, Bank Indonesia
2. Direktur Pengelolaan Kas Negara, DJPB, Kementerian Keuangan
3. Direktur Evaluasi, Akuntansidan Setelmen, Kementerian Keuangan
4. Kepala KPPN Khusus Pinjaman dan Hibah, DJPB, Kementerian Keuangan
5. Project Manager The Reconstruction for IAN Ar-Raniry (lND-1 121113)
6. Project Manager North Sumatera University Hospital (lND-115)
7. Project Manager Development of Belawan Sibolga Fishing Port (lND-121)
B. Project Manager The Upgrading and Development of the lslamic University of Sunan Gunung
Djati, Bandung Project (lND-1261 127)
9. Project Manager The Development and Upgrading State University of Jakarta
(rND-129/130)
10. Project Manager The Development of Belawan Port (lND-133)
11. Project Manager Development of Medical Education and Research Center and Two University
Hospitals Project (Ul, UNAND, UNS) (lND-1371138)
12. Project Manager The Quality lmprovement of Padjajaran University - Bandung (lND-140/141)
13. Project Manager The PNPM ICDD Project Phase ll (lND-0147114811491150/151)
14. Project Manager The Development and Quality lmprovement of the Semarang State
University ( ND-1 521 1 531 1 54)
15. Project Manager The Reconstruction and Upgrading of the State University of Padang
(rND-155/156)
16. Project Manager The Development and Quality lmprovement of State Institute of lslamic
Studies Sunan Ampel Project in Surabaya (lND-157/158)
17. Project Manager The Regional Roads Development Project (lND-161)
18. Project Manager The Support to Quality lmprovement of lslamic Higher Education
(rND-164)
of
|
a4-N0u-2013 A9:55
FRDN IDB REGIDNAL OFFICE
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ISLAMIC DEVELOPMENT BANK
REGIONAL OFFICE
KuelN Lumpur, Maleyile.
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TOGETSER WE BUILD A BEfiDR FIIfURE
Ref:
ttb
93/ t 13
24Dnil Hijja la34H
29 October 2013
Yth. Ms. Ayu Sukorini
Director, Directorate of Ftutds
Directoratc General of Debt Management
Ministry of Finance
Jakarta, Indonesia
Fax:6221-l8l-2859
Dear Ms. Ayu Sukorini,
Subject:
r:t3.Jpj ell
{.rJJ
IDB Prescribed Forms for Dlgbursement Applications
FtrJo
d-Jl
With ret'erence to the abovc, we are plcascd to enclose herewith for your kind attention and
perusal the IDB prescribed forms for submining Disbursement Applications or what is
conmonly known in Indonesia as "Withdrawal Applications (WAs)".
(i) dircct payments, (ii) reimburse.meots, ald (iii) special
prescribed
forms to be used are "Form A: Disbursernent
IDB
or imprest accounts, the
Applicarion Form" and "Form C: Summary Ststement". Wheteas lbr Issuance of an
Irrwocable Commitment to Reimburse (ICR) under Lettcrs of Crcdit, which are usually
Please note thar for cases involving
processed by the Central Bank of Indonesia, the prescribed fonns to be used are Form
B and
l'orm C,
We would like to take this opporlunity to express our sincere appreciatiou
of pur
kind
assislance and cooperation to distribute the above Disbursernent Fonns accordingly.
Yours Sincerely
{
t/
^ \rnlEn,
'
\YWlresubrate
Kunrat
Acting Dircctor
Regional Office Kuala Lumpur
c.c.
- Tbe Director, Country Department
- Ttre Director, Financial Control Departmcnt
- The Director, Multilateral Foreign Financing, BAPPENAS, Indonesia
Sulte l, Levcl 13, Manrrt Ernk Pornbrngunrn, Erodit Wlwarto, Jalro Suluo lcmril
10250 Kurfe Lumpur, Tel. No, 03-2694-6617 Frr. No.03-2694{626 E-mrll: ldbrokl(@isdb.org
http://rww.irdb.org
'"Y
Islamic Development Bank
A
Disbursement Application Form
The Director
Financial Control Dept., 17th Floor
lslamic Development Bank
PO Box 5925
Jeddah 21432, SAUDI ARABIA
Tel: 966 12636 1400
1 Date
2 IDB Project
no.
3 Application no.
3a Contract no.
4 Cofinanciers ref
5 Project name
6 Application for payment of (amount & currency)
7 Type of disbursement:
oirect
paymeni
(ln words)
E
nGimnwsement
E
8 Payment instructions
a Payee name
b Payee address
c Payee account number
d Payee Bank name
e Payee Bank address
f Payee
Bank code
g Payee Bank SWIFT code (if appticabte)
h Corresoondence Bank
I Special payment instructions
and other references
9 The borrower applies
for payment in accordance with the terms and conditions of the Financing
with the lslamic Development Bank. The
date)...
Agreement dated linserr
borrower certifies and agrees to the following:
a The amount requested is required solely for the payment or reimbursement for payment for goods and services
as described in the attached summary statement(s).
b The expenditures were or will be for the sole purpose of the Project as specified in the financing Agreement and
the cost and procurement terms are in accordance with the relevant contract(s).
c No amount has been previously withdrawn or applied for to meet these expenditures.
d No other funds have been or will be obtained by any other loan, credit or grant (from IDB or any other source)
for the purpose of fully or partially meeting these expenditures.
e At the date of this application the borrower is not in default of any obligations under any financing agreement
with the lslamic Development Bank.
f The amount requested is consistent with the percentage financed by the lslamic Development Bank for these
expenditures as specified in the Financing Agreement.
g The goods and services have been procured in accordance with procedures outlined in the Financing
Agreement and are from eligible sources.
h For expenditure claimed on the basis of a Statement of Expenditure (SOE), all documentation which verifies
these expenditures is retained in the location stated on the summary sheet and is available for review by the
Bank or auditors uoon request.
'10 This application consists of linsert no).......... page(s) including (insert no)........... summary statement(s).
11
a Name of Borrower
b Signature(s) of Authorized
Representative(s)
c Print Name & Title of
Signator(y)(ies)
* Please ensure your application and annexes are complete and correct to avoid any delays
*
Islamic Development
Bank
Disbursement Application Form - Instructions for completion
This form is applicable to all types of disbursement requests except for payments under Letters of Credit (UC), or
payments for equity participation.
Notes:
a
b
c
d
e
Please read these instructions before completing the application form.
These instructions should be read in conjunction with the Disbursement Handbook.
Prepare separate application forms for each payee and each currency.
Proforma Summary Statement(s) must accompany application forms, and constitute an integral part of
disbursement application.
Please check the application form before submitting it to the Bank.
Mistakes and omissions lead to delavs in
Numbers correspond to numbers on the Disbursement Application Form.
1 Date: Date signed by the Authorized Representative, not the preparation date.
2 Project no: IDB reference number as advised by the Bank (e.9. 1-lND-0015).
3 Application no: Please number applications consecutively under each project. The first application being number 1.
3a Contract no: Enter the reference number of the contract under which the payment is being made.
4 Cofinanciers ref: Enter the cofinanciers name and reference number, if any.
5 Project name: Enter the project name as it appears in the financing agreement.
6 Application for payment: Enter the total amount applied for including currency details (e.9. USD 50,000.00).
7 Type of disbursement: Please tick the box indicating the type of disbursement. Direct payment being payments
direct to the supplier and reimbursements being payments to the borrower in respect of payments already made to
the supplier.
8 Payment instructions:
a
b
c
d
e
f
g
h
Name of payee, as it appears on their bank account.
Full postal address of payee.
Account number of payee, as it appears on their bank account.
Full name of the bank to which payment is to be made.
Full postal address ofthe branch ofthe bank at which the payees account details are kept.
Bank code of the branch to which payment should be made.
Please provide the bank's SWIFT code, if it is a member of SWIFT.
Please provide any special details and/or references which will expedite payment and allow the payee to
identify the source of funds being transferred.
9 Warranties: Please enter the date the financing agreement was approved and read through the warranties
carefully.
'10 Please enter the total number of pages of the application, excluding contracts and other documents, and enter the
11
total number of summary statements completed with the application.
a Please enter the name of the borrower as it appears on the Financing Agreement.
b Please ensure that all required authorized signatories sign to approve the application, especially in case of
there being more than one class of signatory.
Any changes to the authorized signatories should be submitted with the application.
c Print name and title of authorized signatories who have signed the form and indicate theirclass in case of there
being more than one class of signatory.
Supporting documents to be submitted with disbursement application forms
or more of the following documents is normally provided with the application form.
i Supplier's invoice indicating goods and services supplied, and certified by the borrower, or a summary
of works performed signed by the supervising engineer or other authorized official.
ii Documentary evidence of payment, in cases of reimbursement, of amount due to the supplier, e.g.:
Receipted invoice or formal receipt of the supplier
Cancelled cheque or bank report confirming payment.
iii Evidence of shipment made in cases where goods have been imported. This can be one of the following.
Copy of the Bill of Lading.
A statement by the suppliers or shipping agents certifying the goods have been shipped and indicating the date
and means of shipment, port of destination and description of goods shipped.
iv Claims for payment for insurance, freight costs and other importing costs should be presented in a manner
which clearly identifies the goods to which these costs apply.
a
b
a
b
v Two copies of the contract must be submitted to the IDB for approval prior to the disbursement application (or
with the first disbursement under the contract), if the goods and services are provided under contract.
** Further copies of the contract are not required to be submitted with each withdrawal application **
vi Subsequent disbursement requests under a contract already submitted should clearly refer to the contract
include a certificate from the engineer in charge of implementation of the project or a certified progress
indicating the amount due and referring to the payment terms in the contract.
vii A certificate from the consultant is required with disbursement requests stating that the work subject of
withdrawal request has been completed, if there is a consultant supervising project implementation.
viii
A performance security such as a bank guarantee (as specified in the Agreement), is required for adva
payments under a contract.
These documents may be retained at a specified location for later inspection and not submitted with the
from the IDB: e.o. in the case of Statement of
and Soecial Accounts.
A
Islamic Development Bank
Disbursement Application Form
B
(lssuance of lrrevocable Commitment to Reimburse under letters of credit)
The Director
Financial Control Dept., 17th Floor
lslamic Development Bank
PO Box 5925
Jeddah 21432, Saudi Arabia
Tel: 966 12 636 1400
5 Project name
6 Letter of Credit
1 Date
2 Project
no.
3 Apptication no.
4 Cofinanciers ref
(L/C) amount
7 Letter of Credit Number
8 L/C Expiry date and L/C Shipping date
Expiry date
Shipping Date
9 Payment instructions
a. lssuing Bank name
Address
SWIFT Code
b. Beneficiary/Supplier name
Address
c. Advising/Negotiating Bank's name(s)
Address(es)
SWIFT Code(s)
d. Special payment instructions
and other references
'10
The recipient applies for a withdrawal in the form of an lrrevocable Commitment to Reimburse (lCR) for an
amount of (in letters)
.
,...............in respect of the above letter of credit (L/C) in accordance
with the terms and conditions of the Financing Agreement dated linsert date)............with the lslamic
Development Bank (lDB), and the receipient certifies and agrees to the following:
a The recipient irrevocably authorizes withdrawal on the basis of any written statement by the Correspondent Bank that
payment has been made or, is due and will be made promptly, under and in accordance with the terms of the L/C (as
may be amended).
b Amendments to the terms of L/C that relate to (i) amount, (ii) the country of origin, (iii) the goods description, (iv) the
quantity of goods and (v) the insurance details, are subject to prior approval by the IDB under this lCR.
c The obligations under the ICR shall terminate:
i upon the earlier of the closing date of the financing agreement and 30 days after the expiration of the L/C,
unless the IDB shall agree othenvise;
ii upon payment of the full value of the L/C in accordance with the terms and conditions of the ICR;
iii upon receipt of written notice of cancellation of the UC, in accordance with the terms and conditions of the lCR.
d The amount requested is required solely for the payment of goods and services as described in the attached
summary statement(s).
e The expenditures will be for the sole purpose of the Project as specified in the Agreement and the costs are
reasonable and in accordance with the relevant contract(s).
f No amount has been previously withdrawn or applied for to meet these expenditures.
g No other funds have been or will be obtained by any other loan, credit or grant for the purpose of fully or partially
meeting these expenditures.
h At the date of this application the recipient is not in default of any obligations under any financing agreement with the
lslamic Develooment Bank.
i The amount requested is consistent with the percentage financed by the lslamic Development Bank for these
expenditures as specified in the Financing Agreement.
j The goods and services have been procured in accordance with procedures outlined in the Financing Agreement
and are from eligible sources.
I 1 This application consists of {insert no}... ... .... page(s) including {insert no}.
12
summary statement(s).
a Name of Recipient
b Signature(s) of Authorized
Representative(s)
& Title of
c Print Name
Signato(y)(ies)
d Date of signature
* Please ensure your application and annexes are complete and correct to avoid any delays
*
Islamic Development Bank
Disbursement Application Form - Instructions for completion
This form is only applicable to requests for issuance of lrrevocable Commitment to Reimburse (lCR) under letters
of credit (UC).
Notes:
a
b
c
d
e
Please read these instructions before completing the application form.
These instructions should be read in conjunction with the Disbursement Handbook.
Prepare separate application forms for each payee and each currency.
Proforma Summary Statement(s) must accompany application forms, and constitute an integral part of the
d isbursement application.
Please check the application form before submitting it to the Bank.
Mistakes and omissions lead to delavs in
Numbers correspond to numbers on the Disbursement Application Form.
1 Date: Please insert date of preperation.
2 Project no: IDB reference number as advised by the Bank (e.9. 1-lND-0015).
3 Application no: Please number applications consecutively under each project. The first application being number 1
4 Cofinanciers ref: Enter the cofinanciers name and reference number, if any.
5 Project name: Enter the project name as it appears in the financing agreement.
6 Letter of Credit (L/C) amount: Enter the total amount applied for on the L/C including currency details (e.9. USD
50.000.00).
7 Letter of Credit (L/C) Number: Enter the L/C number as it appears on the L/C.
8 L/C Expiry date and L/C Shipping date: Enter expiry date of L/C and shipping date from the L/C.
9 Payment instructions:
a
b
c
d
e
Name and full postal address of beneficiary/supplier of goods as it appears on the L/C.
Name and full postal address of the issuing bank i.e. applicant's bank,
Name and full postal address of Advising /Negotiating bank.
Please provide the bank's SWIFT code, if it is a member of SWIFT.
Please provide any special details and/or references which will expedite payment and allow the payee to
identify the source of funds being transferred.
10 Insert date agreement was signed. Attention should also be given to point Nos. 'l0a-10j.
11 Please enter the total number of pages of the application, excluding contracts and other documents, and enter the
total number of summary statements completed with the application.
12 a Please enter the name of the recipient as it appears on the Financing Agreement.
b Please ensure that all required authorized signatories sign to approve the application, especially in case of
there being more than one class of signatory.
Any changes to the authorized signatories should be submitted with the application.
c Print name and title of authorized signatories who have signed the form and indicate their class in case of there
being more than one class of signatory.
d Please insert date of sionature.
Supporting documents to be submitted with disbursement application forms
The following documents should accompany the application:
I One copy of the contract of purchase order (unless this cocument has already been submitted to the bank.
iii Two copies of the letter of credit (with valid expiry date) that the commercial bank proposes to issue.
iii One copy of the performance Guarantee in accordance with the IDB's Procurement Procedures (unless
document has alreadv been submitted to the bank.
NB. These documents may be retained at a specified location for later inspection and not submitted with the disbursemen
ication bv orior aooroval from the IDB: e.q. in the case of Statement of
and Soecial Accounts.
Islamic Development Bank
c
Summary Statement
t
+ Sheet no
s Total no of sheets
Date
z Project no.
s Application no.
6
I
I
10
Item
Brief description
& country of oriqin
Name & address of
supplier/contractor
Contract
date & no
no.
Cateqorv
1l
Total
Cost
12
13
14
15
16
17
Previous
Total
oue
IDB
IDB
oavable
Due date/
date paid
Remarks
paYments
18
ts Signature(s) of Authorized
Representative(s)
zo Print Name & Title of
Signato(y)(ies)
%
Islamic Development Bank
c
Disbursement Application Summary Statement - Instructions for completion
Notes:
a Please read these instructions before completing the summary sheet.
These instructions should be read in conjunction with the Disbursement Handbook.
b Prepare separate summary sheets for each application and group of
c
expenditure.
Please check the summary sheet before submitting it to the Bank.
d Attach requisite supporting documents in the same order in which they
appear on the summary sheet.
e Mistakes and omissions lead to delavs in pavment.
Numbers correspond to numbers on the Summary Sheet.
1 Date: Date signed by the Authorized Representative, not the preparation date.
2 Project no: Same as on the Disbursement Application Form.
3 Application no: Same as on the Disbursement Application Form.
4 Sheet no: Number each summary sheet that accompanies an application, beginning with
numoer one.
5 Total no of sheets: Please enter the total number of summary sheets used with the
disbursement application form.
6 ltem
no:
ldentifies item sequentially within each summary sheet, and facilitates
identification of the relevant item to the annexes and in any correspondence.
7 Category: Indicates category of expenditures as specified in the Financing Agreement.
Different categories of goods and services may have different percentages of IDB financing.
8 Brief description & country of origin: Please provide a brief description of the
expenditure, e.g. concrete, steel pipes, structural engineer, and indicate the country of
origin of the goods or services. ln case of payment via a Letter of Credit (L/C), enter the
description of godds as they appear on the L/C.
9 Name and address of supplier/contractor: Please provide the name, city, state and
country of the supplier/contractor.
10 Contract date & no: Provide full reference of the contract and date or purchase order so
that it may be readily identified.
11 Total Gost: Provide the total cost and currency of the contract or purchase order. This may
be different from the amount requested.
12 Previous payments: Enter the amounts previously paid to the supplier (not including this
application) in respect of this contract or purchase order.
'13 Total due/paid: Enter the total amount due or paid to the supplier for this request.
14 IDB %: Enter the percentage of financing payable by the Bank under this category of
goods/services as stated in the Financing Agreement.
15 IDB payable: Enter the amount requested from the Bank for this item (equal to item 13
multiplied by item 14).
16 Due date/date paid: Enter the due date for payment or actual date of payment (in the case
of a reimbursement).
17 Remarks: Cross reference the item to the annexes, or provide the location where the
documents are kept and provide any other details that will aid in the approval of the
application.
total: Enter the total monetary sum of the amount applied for on this sheet, indicating
the currency requested.
19 & 20 Signature(s): Authorized Representatives are required to approve the summary sheets as
well as the application form.
1B Sheet