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Health Declaration Form

HEALTH DECLARATION FORM

shares listed in the Register of Shareholders of PT Ciputra Development Tbk (the Company) at the close of trading on the Indonesia Stock Exchange on July 6, 2021, with a total issuance of shares by the Company of 18,560,303,397 (eighteen billion five hundred sixty million three hundred three thousand three hundred ninety seven) shares. In connection with the holding of the Annual and Extraordinary General Meeting of Shareholders (“Meeting”) held on Thursday, July 29, 2021, in Jakarta, hereby declare actually as follows:

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Note

*) select one

If one of the answers for No. 1, 2, and 3 is Yes, you are not permitted to enter the meeting room and attend the meeting. If you currently experiencing one of the symptoms stated in No. 4, you are not permitted to enter the meeting room and attend the meeting.