PT. PERTAMINA (Persero)
             Penilaian Tingkat Kesehatan Keuangan Calon Penyedia Barang/Jasa
             PT. ……………                                                    Periode 2016, 2017 dan    Mata Uang 
                                                                          2018.                     Menyesuaikan dengan 
                                                                                                    Lap. Keuangan Masing2 
                 Data input :                                                                       tidak dikonversi
                 Nama Perusahaan
                 Domisili
                 Jenis Usaha
                 Mata Uang 
                 Periode Pelaporan
                 Trend Analysis                                                                            -                                                -                                                -   
                                                                Dec 2016                Dec 2017               Dec 2018 
                1Asset
                 Cash & Cash Equivalents
                 Restricted Cash
                 Short-term Investment
                 Cash                                                                                        -                                                -                                                - 
                 Inventory
                 Trade Receivables-Related Parties
                 Trade Receivables-Third Parties
                 Trade Receivables-Other Parties
                 Trade Receivables                                                                         -                                                -                                                -   
                 Total Current Assets
                 Total Non Current Asset
                 Construction in Progress
                 Total Assets                                                                                -                                                -                                                - 
                2Liabililties & Equity
                 Trade Payables-Related Parties
                 Trade Payables-Third Parties
                 Trade Payables                                                                              -                                                -                                                - 
                 Total Current Liabilities
                 Total Liabilities
                 Total Equity
                                                                  OK                      OK                     OK
                3Comprehensive Income
                 Revenue
                 Cost of sales
                 Gross Profit                                                                                -                                                -                                                - 
                 EBITDA                                                                                      -                                                -                                                - 
                 Interest Expense
                 Depreciation & Amortization
                 EBIT                                                                                        -                                                -                                                - 
                 Tax Expense (Income)
                 Net Profit
                3Others
                 Opini Audit
                 Auditor/KAP
                 Domisili Auditor/KAP
                 * Opini Audit: 
                 - Wajar tanpa pengecualian (Unqualified)
                 - Wajar tanpa pengecualian dengan Penjelasan (Unqualified with Explanatory)
                 - Wajar dengan pengecualian (Qualified)
                                                                                                       Tempat, tanggal ……………………
                                                                                                       PT. ………………….
                                                   (Nama Pejabat)
                                                   Jabatan