| No. | Uraian | Index | |
|---|---|---|---|
| 1 | Fungsi Bangunan (If) | 
                                         0  | 
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| 2 | Kompleksitas(Ik) | 
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| 3 | Tingkat Permanensi(Ip) | 
                                         0  | 
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| 4 | Jumlah Lantai(Il) | 
                                         0  | 
                                |
| 5 | Status Kepemilikan(Fm) | 
                                         0  | 
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| 6 | Indeks Terintegrasi(It) | ||
| 7 | Indeks BG Terbangun(Ibg) | 
                                         0  | 
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| 8 | Indeks Lokalitas(Ilo) | 
                                         0  | 
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| 9 | Standar Harga Satuan Tertinggi (SHST) | ||
| No. | Uraian | Luas (m2) | 
|---|---|---|
| 1 | ||
| 2 | ||
| 3 | ||
| 4 | ||
| 5 | ||
| 6 | ||
| 7 | ||
| 8 | ||
| 9 | ||
| 10 | ||
| Luas Total Bangunan (LLt) | ||
| 
                                    NILAI RETRIBUSI BANGUNAN GEDUNG (It x Ibg x Ilo x SHST x LLt)  | 
                                ||
| No. | Uraian | Volume | Satuan | Harga | Jumlah | 
|---|---|---|---|---|---|
| 1 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 2 | 
                                                                             
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| 3 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 4 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 5 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 6 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 7 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 8 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 9 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| 10 | 
                                                                             
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                                         0  | 
                                    
                                         0  | 
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| NILAI RETRIBUSI PRASARANA | 
                                     0  | 
                            ||||
| 
                                    TOTAL NILAI RETRIBUSI (NILAI RETRIBUSI BANGUNAN GEDUNG + NILAI RETRIBUSI PRASARANA)  | 
                                
                                     0  | 
                            ||||