Dengan ini kami informasikan bahwa orang tersebut dibawah ini telah ditolak masuk wilayah RI berdasarkan pasal 13 dan pasal 18 ayat 1 (f) Undang- Undang No.6 Tahun 2011 tentang Keimigrasian, dan berdasarkan Annex 9 Konvensi Penerbangan Sipil Internasional, negara terakhir yang ditinggali dan paling akhir dikunjungi dihimbau untuk menerima kembali tersebut penumpang manakala yang bersangkutan ditolak masuk di Bandar Udara Internasional I Gusti Ngurah Rai. This is to inform the appropriate authority that the person mentioned below is refused entry into Indonesian territory pertaining to the art. 13 and art. 18 clause 10 Act No. 6 in the year of 2011 concerning Immigration, and in accordance to Annex 9 to the Convention on International Civil Aviation, the last state in which a passenger previously stayed and most recently travelled from is invited to accept him her from re-examination when he she has been refused entry into I Gusti Ngurah Rai International Airport