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I, the undersigned, hereby declare that the above details and statements
are correct; that all the goods were produced in
___________________________________________________
TRINIDAD AND TOBAGO (country)
and that they comply with the provisions governing the determination of
origin set out in Articles 14 and 16 of the Schedule II to the Annex to the
Treaty establishing the Caribbean Community.

11/01/2023 Trinidad 11/01/2023

Place and date, signature and stamp of certifying authority Place and date, signature of authorised signatory
 NOTES FOR THE PREPARATION OF THIS FORM

A. Origin Criterion

The criterion on the basis of which Common Market origin is claimed must be stated in
the column headed "Origin Criterion" against each item in the manner indicated below:

If each article comprised in the item has been —

(a) wholly produced within the Common The letter "CM" must be inserted;
Market.

(b) produced using materials imported The tariff heading number of the
from outside the Common Market or finished product preceded by the
of undetermined origin in such a letter "X" must be inserted;
manner that the article fails to be
classified in a tariff heading
different from that in which any of
those materials is classified, in
accordance with the provisions of
Article 84 of the Annex to the Treaty
establishing the Caribbean
Community;
(c) produced in accordance with the The tariff heading number of the
conditions specified for that article finished product preceded by the
in the List referred to in Article 84 of letter "L" must be inserted and
the Annex to the Treaty establishing where the condition to be
the Caribbean Community and set satisfied is a percentage value
out in Schedule II therefore; added condition value of
materials imported from outside
the Common Market or of
undetermined origin which have
been used in the production of
that article expressed as a
percentage of the export price of
the article must be inserted in
brackets immediately following
the tariff heading number.
B. The completion of this Form implies that the producer and the exporter will furnish to the
appropriate authorities such information and supporting evidence as they may as
necessary require for the purpose of verifying these declarations.

C. PERSONS WHO FURNISH OR CAUSE TO BE FURNISHED UNTRUE DECLARATIONS

RENDER THEMSELVES LIABLE TO PENALTIES.

Dated this : ______________________