117586911301

1. Goods consigned from (Exporter's business name, Reference No. 0001546/GRS/2022

address, country)

PT LANGGENG BUANA JAYA ASEAN-KOREA FREE TRADE AREA

VETERAN MADYA NO.8 PREFERENTIAL TARIFF
INDONESIA
CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)

2. Goods consigned to (Consignee's name, address, FORM AK

country)
Issued in INDONESIA
BOMNAMU CO., LTD, (Country)
#406, HANAN EZ TOWER, 43BEON-GIL, 10,
SEONGNAM-DAERO, BUNDANG-GU, SEONGNAM-SI, See Notes Overleaf
GYEONGGI-DO, 13636
REPUBLIC OF KOREA
3. Means of transport and route (as far as known) 4. For Official Use

Preferential Treatment Given Under ASEAN-Korea

Departure Date FEBRUARY 1, 2022 Free Trade Area Preferential Tariff

Vessel's name/Aircraft etc. RIO GRANDE 2201N Preferential Treatment Not Given (Please
state reason's)

Port of Discharge BUSAN (EX PUSAN)

.........................................................................................
Signature of authorised Signatory of the Importing
Country

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criterion 9. Gross weight or 10. Number
number numbers on description of goods (including (see Notes other quantity and date
packages quantity where appropriate and Overleaf) and value (FOB of invoices
HS number of the importing country) only when RVC
criterion is used)

1 N/A 150 CARTONS SAID TO CONTAIN 600 UNITS RVC 68% 600 H87 039/EXP.LBJ/012
(PCE) 901.35 KGM 2
641 DYSON BALL USD 2,424 JANUARY 27,
PO#6096 2022
HS: 950300 0000134193
FEBRUARY 1,
2022

2 N/A 925 CARTONS SAID TO CONTAIN 5550 UNITS RVC 68% 5,550 H87 039/EXP.LBJ/012
(PCE) 6,539.57 KGM 2
687 DYSON CORD-FREE VACUUM USD 19,425 JANUARY 27,
PO#6096 2022
HS: 950300 0000134193
CASDON LTD FEBRUARY 1,
UNITED KINGDOM 2022

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details It is hereby certified, on the basis of control carried out,
that the declaration by the exporter is correct.
and statements are correct; that all the goods were
produced in
ISSUED RETROACTIVELY
INDONESIA ISSUING OFFICE IN KABUPATEN GRESIK
..........................................................
(country)

and that they comply with the origin requirements

specified for these goods in the ASEAN-KOREA Free
Trade Area Preferential Tariff for the goods exported to

REPUBLIC OF KOREA
..........................................................
(Importing Country) AGUS BUDIONO

GRESIK, FEBRUARY 16, 2022

.......................................................... GRESIK, FEBRUARY 16, 2022
Place and date, signature of
authorised signatory ...............................................................................................
Place and date, signature and stamp of certifying authority

13. v Third Country Invoicing Exhibition Back-to-Back CO

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