116395155638

1. Products consigned from (Exporter's business name, address, country) Reference No. 0000861/JKT/2022
PT. PAN PACIFIC JAKARTA
JLN KALIMANTAN RAYA BLOK D-27 KAWASAN ASEAN-CHINA FREE TRADE AREA
BERIKAT NUSANTARA CAKUNG CILINCING RT.002 PREFERENTIAL TARIFF
RW.002
14140 JAKARTA
CERTIFICATE OF ORIGIN
INDONESIA (Combined Declaration and Certificate)
2. Products consigned to (Consignee's name, address, country)
FORM E
H & M HENNES MAURITZ (SHANGHAI) COMMERCIAL CO.LTD
B1-3F, 645-659 MIDDLE HUAI HAI ROAD
LU WAN DISTRICT Issued in INDONESIA
SHANGHAI
PEOPLES REPUBLIC OF CHINA
See Overleaf Notes

3. Means of transport and route (as far as known) 4. For Official use

Departure Date DECEMBER 31, 2021 Preferential Treatment Given

Vessel's name/Aircraft etc. SPECTRUM N V. 023N Preferential Treatment Not Given (Please state reason/s)

.................................................................................................................
Port of Discharge SHANGHAI, CHINA
Signature of Authorised Signatory of the Importing Party

5. Item 6. Marks and 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number,
number numbers of description of products (including (see Overleaf or net weight or date of invoices
packages quantity where appropriate and Notes) other quantity and
HS number in six digit code) value (FOB) only
when RVC
criterion is applied

1 CNW051 38 CT PSR 3,156 PCE 10602/PPJ/XII/21

3156 PIECES OF (THREE THOUSAND DECEMBER 20, 2021
BLOUSE WOMEN WOVEN ONE HUNDRED AND CN-26-64493-3
100% POLYESTER FIFTY-SIX) DECEMBER 30, 2021
SUPPLIER NO.: 0574 GW :
ORDER NO.: 211064-1515 501.80 KGM
COUNTRY : CN (FIVE HUNDRED AND
HS: 621143 ONE POINT EIGHTY)
NW :
H&M HENNES & MAURITZ GBC AB 465.09 KGM
MASTER SAMUELSGATAN 46 A SE-106 38 (FOUR HUNDRED
STOCKHOLM SWEDEN AND SIXTY-FIVE
SWEDEN POINT ZERO NINE)

11. Declaration by the exporter 12. Certification

The undersigned hereby declares that the above details and statement are It is hereby certified, on the basis of control carried out, that the declaration by
correct; that all the products were produced in the exporter is correct

INDONESIA ISSUING OFFICE IN PROVINSI DKI JAKARTA

.....................................................................
(Country)

and that they comply with the origin requirements specified for these
products in the Rules of Origin for the ACFTA for the products exported to

CHINA
.....................................................................
(Importing Country)

JAKARTA, JANUARY 5, 2022

..........................................................................................................
Place and date, signature of authorised signatory

BADIA RAJA H. SIREGAR

13.
v
Issued Retroactively Exhibition JAKARTA, JANUARY 5, 2022
.............................................................................................................
Movement Certificate v Third Party Invoicing Place and date, signature and stamp of certifying authority

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