ORIGINAL
Reference No. VN-ID 24/02/008027
1. Goods Consigned from (Exporter's business name, address, country)
LOUIS DREYFUS COMPANY VIETNAM TRADING AND PROCESSING CO. LTD.
LOT A11, TRA DA INDUSTRIAL ZONE, TRA DA COMMUNE, PLEIKU CITY, GIA LAI
ASEAN TRADE IN GOODS AGREEMENT
PROVINCE, VIET NAM
CERTIFICATE OF ORIGIN
VIET NAM
(Combined Declaration and Certificate)
2. Goods consigned to (Consignee's name, address, country) FORM D
PT. TORABIKA EKA SEMESTA
Issued in VIET NAM
GEDUNG MAYORA; JL. TOMANG RAYA NO. 21-23; TOMANG - GROGOL
(Country)
PETAMBURAN JAKARTA BARAT, DKI JAKARTA 11440; TAX ID : 01.333.792.8-
038.000 See Overleaf Notes
INDONESIA
3. Means of transport and route (as far as known) 4. For Official Use
Departure Date: 23/01/2024 ☐ Preferential Treatment Given Under ASEAN Trade in Goods Agreement
Vessel's name/Aircraft etc.: STARSHIP JUPITER 2401S
☐ Preferential Treatment Not Given (Please state reason/s)
Port of Discharge: JAKARTA (INDONESIA)
..........................................................................................
Signature of Authorised Signatory of the Customs Authority of the Importing Country
5. Item number 6. Marks and numbers on 7. Number and type of packages, description of 8. Origin criterion 9. Gross weight or 10. Number and
packages goods (including quantity where appropriate and (see Overleaf other quantity and date of invoices
HS number of the importing country) Notes) FOB price where
RVC is applied
1 SEE BILL GREEN COFFEE VIETNAM ROBUSTA GRADE 1 SCREEN WO 191,205.00 FS-98077
18; LDCS REFERENCE: S-88578
KILOGRAM DATE: 23/01/2024
HS CODE: 09011130
189,000.00
3,150 BAG
TCI: LOUIS DREYFUS COMPANY SUISSE SA (COFFEE KILOGRAM
DIVISION),
29, ROUTE DE L AEROPORT P.O.BOX 236 CH-1215
GENEVA 15, SWITZERLAND, SWITZERLAND
11. Declaration by the exporter 12. Certification
The undersigned hereby declares that the above details and statements are It is hereby certified, on the basis of control carried out, that the
correct; that all the goods were produced in declaration by the exporter is correct.
VIET NAM
(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
INDONESIA
(Importing country)
GIA LAI, 24/01/2024
HO CHI MINH, 24/01/2024
Place and date, signature of authorised signatory
Place and date, signature and stamp of certifying authority
13.
Third Country Invoicing Exhibition
Accumulation De Minimis
Back-to-Back CO Issued Retroactively
Partial Cumulation
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