ETHIOPIAN CUSTOMS

COMMISSION
DECLARATION FORM
2021 / AAA00 / 4 / 2020 1 DECLARATION A. CLEARANCE OFFICE AA Airport
2 Consignor/Exporter No Office Code Manifest Number
MSF SUPPLY CHAUSSEE DE VILVOORDE 140 1120 BRUXELLES.BRUSSEL IM 4 AAA00 ET725 2021-01-06
BELGIUM BE
3 Forms 4 Loading Lists Registration number & date Assessment number & date
1 2 4-002020 26/01/2021 A-004038 26/01/2021
5 Items 6 Tot. Pkgs. 7 Declarant Reference number Receipt number & date
4 7 2021 / IM0023 R-006518 01/02/2021
8 Consignee/Importer No 0001017800 No 10 Country of Last
9 Person responsible for financial settlement
MEDECINS SANS FRONTIERES HOLLAND BE Consign.
ADDIS ABABA
ADDIS ABABA 11 Trading

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

Belgium a BE b a ET b ET
14 Declarant No 0043402730 16 Country of origin 17 Country of destination Section
GPS LOGISTICS Belgium Ethiopia GN
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
ET725 EUR 6,175.26 48.2506 transactio
21 Identity and nationality of active means of transport crossing the border 28 Financial and banking data 24 Invoice Details

ET725 Bank Code Currency Amount

Ex. Freight ETB 102,822.00
25 Mode of transport 26 Inland mode 27 Place of Loading
at the border of transport
Branch Terms of Payment Insurance ETB 5,959.00
4 4 Brussel (Bruxelles) BEBRU
0 FRANCO Other ETB 7,013.00
29 Office of entry/exit 30 Location of goods
B. P. number and date In. Freight ETB 0.00
AAA00 AA Airport Total ETB 115,794.00
31 Packages Marks & 32 Item 33 Commodity Code
and numbers 1 No 39269090 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 BE b 200
Description of goods 42 a 37 PROCEDURE 38 Net mass (kg) 39 Quota
--- OTHER Ex. Freight 19,269.00 4000 406 200
TAP,APRON PROTECTION,BAG BODY PLASTIV Insurance 1,117.00 40 Summary declaration/Previous document / Way bill
Other Costs 1,314.00 071-39723412
In. Freight 0.00
41 Supplementary units 42 Item price 43 V.M.

44 Additional 1,157.28 Code

License number Deducted Quantity Deducted Value
Information/ A.I. Code 45 Adjustment
Produced
documents Attached document codes 1
001 004 005 006 402 380 016 510 510 320 46 Statistical Value
Proc. Program
77,539.00
Type Duty/Tax Base Rate Amount MP 48 Account No / Deferred Payment 49 Warehouse code / period
47 Taxes &
duties 01 77,539.00 30 23,261.70 1
03 100,801.00 0 0.00 1 Summary of Payables
04 100,801.00 15 15,120.15 1 Amount

05 115,921.00 10 11,592.10 1 Total duties & taxes 140,307.85

15 77,539.00 0 0.00 1 Guarantee amount 0.00
Total fees 0.00
Other 0.00
Total Payable 140,307.85
Total 49,973.95 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:
 ETHIOPIAN CUSTOMS
COMMISSION
DECLARATION FORM - Continuation sheet

1 DECLARATION A. CLEARANCE OFFICE

8 Consignee/Importer No 0001017800 Office Manifest Number
MEDECINS SANS FRONTIERES IM 4
AAA00 ET725 2021-01-06
HOLLAND
ADDIS ABABA 3 Forms Registration number & date Assessment number & date
ADDIS ABABA
2 2 4-002020 26/01/2021 A-004038 26/01/2021
31 Packages Marks & 32 Item 33 Commodity Code
and numbers 2 No 63062900 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 BE b 200
Description of goods 42 a 37 PROCEDURE 38 Net mass (kg) 39 Quota
--Tents of textiles, (excl. cotton or synthetic fibres) Ex. Freight 41,825.00 4000 411 200
TENT ,SHADE NET Insurance 2,424.00 40 Summary declaration/Previous document / Way bill
Other Costs 2,853.00 071-39723412
In. Freight 0.00
41 Supplementary units 42 Item price 43 V.M.

44 Additional UNT 5 2,511.93 Code

License number Deducted Quantity Deducted Value
Information/ A.I. Code 45 Adjustment
Produced
documents Attached document codes 1
Proc. Program 46 Statistical Value
Model 168,304.00
31 Packages Marks & 32 Item 33 Commodity Code
and numbers 3 No 73090000 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 BE b 200
Description of goods 42 a 37 PROCEDURE 38 Net mass (kg) 39 Quota
Reservoirs, tanks... (excl. for gas) of iron or steel, >=300 l Ex. Freight 17,569.00 4000 406 200
Insurance 1,018.00 40 Summary declaration/Previous document / Way bill
KIT WATER TANK
Other Costs 1,198.00 071-39723412
In. Freight 0.00
41 Supplementary units 42 Item price 43 V.M.

44 Additional 1,055.13 Code

License number Deducted Quantity Deducted Value
Information/ A.I. Code 45 Adjustment
Produced
documents Attached document codes 1
Proc. Program 46 Statistical Value
Model 70,696.00
31 Packages Marks & 32 Item 33 Commodity Code
and numbers 4 No 40094200 000 0000 0000
description
of goods Number & kind of packages 34 Country of origin Code 35 Gross Mass (kg) 36 Preference
Ctr.
No(s) 1 CT Carton (Box) a BE b 249
Description of goods 42 a 37 PROCEDURE 38 Net mass (kg) 39 Quota
TUBE,PIPE&HORSE OFVALCANISIED RUB. REINFORCED WITH OTH.MATE. Ex. Freight 24,159.00 4000 406 249
WITH FITTINGS
Insurance 1,401.00 40 Summary declaration/Previous document / Way bill
MODULE ADDITIONAL HOSES AND MODULE WATER DISTRIBUTION Other Costs 1,649.00 071-39723412
In. Freight 0.00
41 Supplementary units 42 Item price 43 V.M.

44 Additional 1,450.92 Code

License number Deducted Quantity Deducted Value
Information/ A.I. Code 45 Adjustment
Produced
documents Attached document codes 1
Proc. Program 46 Statistical Value
Model 97,217.00
Type Duty/Tax Base Rate Amount M Type Duty/Tax Base Rate Amount MP
47 Taxes &
duties 01 168,304.00 0 0.00 1 01 70,696.00 10 7,069.60 1
03 218,795.00 0 0.00 1 03 77,766.00 0 0.00 1
04 218,795.00 0 0.00 1 04 77,766.00 15 11,664.90 1
05 251,614.00 0 0.00 1 05 89,431.00 10 8,943.10 1
15 168,304.00 0 0.00 1 15 70,696.00 0 0.00 1

Total first item: 0.00 1 Total second item: 27,677.60 1

Type Duty/Tax Base Rate Amount M Type Amount M ← SUMMARY
01 97,217.00 30 29,165.10 1 01 59,496.40 1 C OFFICE OF DEPARTURE
03 126,382.00 0 0.00 1 03 0.00 1
04 126,382.00 15 18,957.30 1 04 45,742.35 1
05 145,339.00 10 14,533.90 1 05 35,069.10 1
15 97,217.00 0 0.00 1 15 0.00 1

Total third item: 62,656.30 1 G.T. 140,307.85 1