1.

Goods consigned from (Exporter's business name, address, country)

PT INTI EVERSPRING INDONESIA
Reference No. -
PLAZA SENTRAL 5B FLOOR
JL. JEND SUDIRMAN NO.47 ASEAN TRADE IN GOODS AGREEMENT
JAKARTA 12930 - INDONESIA CERTIFICATE OF ORIGIN
(Combined Declaration and Certificate)
FORM D
2. Goods consigned to (Consignee's name, address, country)
Issued in INDONESIA
MONARCH AGRICULTURAL PRODUCTS, INC.
5650, DON PEDRO STREET, BRGY. POBLACION, MAKATI CITY, 1210 (Country)
PHILIPPINES
CONTACT PERSON: MR ROBERT C CASTRO / MS MENA P.ESTARAS See Overleaf Notes
CONTACT NO. MANILA: +632 8890-8006 CONTACT NO. DAVAO: +6382 235-1145
(C/O SEA WHALE CUSTOMS BROKERAGE)
3. Means of transport and route (as far as known) 4. For Official Use

Preferential Treatment Given Under ASEAN

Departure Date FEBRUARY 28, 2023 Trade in Goods Agreement

Preferential Treatment Not Given (Please

Vessel's name/Aircraft etc. HYUNDAI VOYAGER 0130N State reason's)

Port of Discharge DAVAO, MINDANAO

Signature of Authorised Signatory of the Customs Authority of the
Importing Country

5. Item 6. Marks and numbers
number on packages
1 CIMOXAMATE 240 SL
(OXAMYL 240 SL)
MONARCH
AGRICULTURAL
PRODUCTS, INC.
PHILIPPINES
ORIGIN: INDONESIA
BATCH NUMBER: 110048,
110049, 110050 & 110051
MANUFACTURING DATE:
JAN 30, 2023, FEB 04,
2023, FEB 06, 2023 & FEB
08, 2023
EXPIRY DATE: JAN 29,
2025, FEB 03, 2025, FEB
05, 2025 & FEB 07, 2023
GROSS WEIGHT: 15,513
KGS
NET WEIGHT: 14,677.72
KGS
7. Number and type of packages, description 8. Origin criterion 9. Gross weight or other 10. Number and
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
750 BOXES IN 15 PALLET "100.00%" GW: AX23010005
15,000 LTS CIMOXAMATE / OXAMYL 240 GR/LT 15,513.000 KGM JANUARY 25,
SL (OXAMYL FORMULATION) (FIFTEEN THOUSAND 2023
PACKED IN 5 LTS UN APPROVED HDPE FIVE HUNDRED
JERRY-CANS THIRTEEN)
USD 113,083.300
NET WEIGHT : 14,677.72 KG
UN/NO : 2991
IMO CLASS : 6.1
PACKING GROUP : III
HS: 380891
2025

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 by
are correct; that all the goods 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
goods in the ASEAN Trade in Goods Agreement for the goods
exported to

PHILIPPINES
(Importing Country)

JAKARTA SELATAN, -
Place and date, signature of authorized signatory
13. Third Country Invoicing Exhibition
Accumulation De Minimis -
Back-to-Back CO Issued Retroactively JAKARTA, -
Partial Cumulation Place and date, signature and stamp of certifying authority

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