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1. Title and Declaration Statement: Formal title of the document and opening declaration statement including the affiant's identity and acknowledgment of making the statement under oath

2. Personal Information: Detailed identification of the affiant including full name, ID number (NIK), date of birth, address, and occupation

3. Income Declaration Period: Specification of the time period for which the income declaration is being made (e.g., previous year, current year to date, or specific months)

4. Primary Income Sources: Detailed listing of main income sources including employment income, business income, or professional services income with specific amounts

5. Total Income Calculation: Summary calculation of total income from all sources for the declared period

6. Verification Statement: Statement confirming the truth and accuracy of the declared information, acknowledging penalties for false statements

7. Execution: Date, place, and signature section including space for notary authentication

1. Schedule A - Income Documentation: Copies of supporting documents such as salary slips, business statements, or tax returns

2. Schedule B - Bank Statements: Relevant bank statements showing income deposits for the declared period

3. Schedule C - Additional Income Proof: Documentation for other income sources such as rental agreements or investment statements

4. Appendix 1 - Identity Documents: Copies of required identification documents (KTP, family card, etc.)

5. Appendix 2 - Tax Registration: Copy of tax registration number (NPWP) card and recent tax filing acknowledgment