I/We undersigned                                              : .......................................…................................................................
(Saya/kami yang bertanda tangan dibawah ini)

Nationality                                                        : ...........................................................................................................
(Kewarganegaraan)

Of and therefore on behalf of                             : ...........................................................................................................
(Oleh karenanya untuk dan atas nama)

A corporation organized under the laws of          : ...........................................................................................................
(Suatu perseroan menurut Undang-Undang)

Residing/having principal office at                       : ...........................................................................................................
(Beralamat/Berkantor Pusat di) 
                                                                           ...........................................................................................................

Located                                                            : …........................................................................................................
(Berkedudukan di)
                                                                          …........................................................................................................

Truthfully certify that with regard to the work/creation, being for copyright :
(Menyatakan bahwa sehubungan dengan ciptaan yang kami mohonkan pendaftaran ciptaannya :)

…………………………………………………………………………………………………………………..

I am/We are the genuine author of its origin, and should there be evidence of piracy accordingly, such registration shall be consequenly liable to cancellation.
(adalah benar-benar ciptaan saya/kami yang tidak meniru orang lain, apabila terbukti milik orang lain kami bersedia dibatalkan pendaftarannya)

So far this statement, draw-up by me/us in good faith and to be used as required.
(Demikian pernyataan ini saya/kami buat dengan sebenarnya dan dipergunakan sebagaimana perlunya.)

Drawn-up in :
(Dibuat di)

Date :
(Tanggal)

The Declare :
(Yang membuat pernyataan)

______________________