ETHIOPIAN CUSTOMS

COMMISSION
DECLARATION FORM
2021 / AAA01 / 4 / 938 1 DECLARATION A. CLEARANCE OFFICE AA Parcel Post (AAP)
2 Consignor/Exporter No Office Code Manifest Number
CENTRALPOINT IM 4 AAA01 DHL2021 2021-01-08
ROBERT VAN DE PAVERT
BIJSTERHUIZEN 24-05 3 Forms 4 Loading Lists Registration number & date Assessment number & date
6604LK WIJCHEN
NETHERLANDS,THE 1 1 4-000938 25/01/2021 A-001214 25/01/2021
5 Items 6 Tot. Pkgs. 7 Declarant Reference number Receipt number & date
1 2 2021 / IM0008 R-003564 25/01/2021
8 Consignee/Importer No 0001024339 No 10 Country of Last
9 Person responsible for financial settlement
MEDECINS SANS FRONTIERES SPAIN NL Consign.
0990/2002
ADDIS ABABA 11 Trading

country
15 Country of dispatch/export 15 C. disp./exp. code 17 Country destin. code

Netherlands a NL b a ET b ET
14 Declarant No 0043402730 16 Country of origin 17 Country of destination Section
GPS LOGISTICS China Ethiopia OG
RG: ADDIS ABABA ZN :BOLE
WR: NO WOREDA-144 KB :WOREDA 14 20. Delivery Terms Business Activity
FOB NG
18 Identity and nationality of means of transport at arrival 19 Ctr. 22 Currency and total amount invoiced 23 Exchange rate 24 Nature of
DHL EUR 3,359.80 48.2506 transactio
21 Identity and nationality of active means of transport crossing the border 28 Financial and banking data 24 Invoice Details

DHL Bank Code Currency Amount

Ex. Freight ETB 8,106.00
25 Mode of transport 26 Inland mode 27 Place of Loading
at the border of transport
Branch Terms of Payment Insurance ETB 3,242.00
4 4 Amsterdam NLAMS
0 FRANCO Other ETB 8,106.00
29 Office of entry/exit 30 Location of goods
B. P. number and date In. Freight ETB 0.00
AAA01 AA Parcel Post (AAP) Total ETB 19,454.00
31 Packages Marks & 32 Item 33 Commodity Code
and numbers 1 No 84713020 000 0000 0000
description
of goods Number & kind of packages 34 Country of origin Code 35 Gross Mass (kg) 36 Preference
Ctr.
No(s) 2 CT Carton (Box) a CN b 12
Description of goods 42 a 37 PROCEDURE 38 Net mass (kg) 39 Quota
--- Lap top computers or note book computers, Presented CBU Ex. Freight 8,106.00 4000 406 12
LAPTOPS DEVICE Insurance 3,242.00 40 Summary declaration/Previous document / Way bill
Other Costs 8,106.00 1623556550
In. Freight 0.00
41 Supplementary units 42 Item price 43 V.M.

44 Additional UNT 4 3,359.80 Code

License number Deducted Quantity Deducted Value
Information/ A.I. Code 45 Adjustment
Produced
documents Attached document codes 1
001 004 005 006 402 510 510 46 Statistical Value
Proc. Program
181,566.00
Type Duty/Tax Base Rate Amount MP 48 Account No / Deferred Payment 49 Warehouse code / period
47 Taxes &
duties 01 181,566.00 5 9,078.30 1
03 190,644.00 0 0.00 1 Summary of Payables
04 190,644.00 15 28,596.60 1 Amount

05 219,241.00 10 21,924.10 1 Total duties & taxes 59,599.00

15 181,566.00 0 0.00 1 Guarantee amount 0.00
Total fees 0.00
Other 0.00
Total Payable 59,599.00
Total 59,599.00 1
50 Declaration C OFFICE OF DEPARTURE

I, Berhanu Desta Iyassu (AG0648), the undersigned of GPS LOGISTICS RG: ADDIS ABABA ZN :BOLE
WR: NO WOREDA-144 KB :WOREDA 14 do hereby declare that the information and particulars declared
are true and complete and accept fully the condition and requirements attaching to the use of CPC declared
here in and hold myself liable for any inaccurate information.

Signature Date & stamp Address

52 Guarantee Code 53 Office of destination (and country)

not valid for

D CONTROL BY OFFICE OF DEPARTURE Stamp: 54 Place and date:

Result:

Seals affixed: Number:

Signature and name of declarant/representative
Identity:
Berhanu Desta Iyassu (AG0648)
Time limit (date):

Signature: