62045861006

1. Goods consigned from (Exporter's business name, address, country) Reference No. 0025295/KTG/2017
PT. POLYMINDO PERMATA
KOMP. KEDOYA ELOK PLAZA BLOK DC NO. 54 KEDOYA SELATAN KEBON
JERUK JAKARTA BARAT DKI JAKARTA 11520
ASEAN TRADE IN GOODS AGREEMENT
INDONESIA ASEAN INDUSTRIAL COOPERATION SCHEME
CERTIFICATE OF ORIGIN
2. Goods consigned to (Consignee's name, address, country) (Combined Declaration and Certificate)
GIA MAN CO., LTD FORM D
113TTH07, QUARTER 3, TAN THOI HIEP WARD, DITRICT 12, HO CHI MINH CITY, Issued in INDONESIA
VIET NAM TEL: +84 903033777 ATTN :TRAN VAN TRI (Country)
VIET NAM
See Overleaf Notes

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

Preferential Treatment Given Under ASEAN

Departure Date JULY 25, 2017 Trade in Goods Agreement

Preferential Treatment Given Under ASEAN

Vessel's name/Aircraft etc. PORT ADELAIDE V.1706N Industrial Cooperation Scheme

Preferential Treatment Not Given (Please

State reason's)
Port of Discharge HO CHI MINH CITY
.................................................................................................................
Signature of Authorised Signatory of the Importing Country

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

1 GIA MAN CO., LTD 52 SACKS OF VIRO SYNTHETIC FIBER RVC 85.77% GW : VR-055/VII/17
INVOICE NO: VR-055/VII/17 1,534.14 KGM JULY 21, 2017
HS: 3916.90 NW :
1,526.86 KGM
USD 6,527.33
(SIX THOUSAND FIVE
HUNDRED AND
TWENTY-SEVEN POINT
THIRTY-THREE)

11. Declaration by the exporter 12. Certification

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

INDONESIA
MUNICIPALITY OFFICE IN TANGERANG
......................................................................................................................
(Country)
and that they comply with the origin requirements specified for
these goods in the ASEAN Trade in Goods Agreement for the goods
exported to

VIET NAM
......................................................................................................................
(Importing Country)

JAKARTA, JULY 26, 2017

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

13.
Third Country Invoicing Exhibition

Accumulation De Minimis EKO CAHYONO

Back-to-Back CO Issued Retroactively TANGERANG, JULY 26, 2017

.......................................................................................................................................
Partial Cumulation Place and date, signature and stamp of certifying authority

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