Page 74 - FTA무역리포트

FTA ANALYSIS 한-인도네시아 CEPA 및 우리나라 기업의 활용방안

[별지 제24호의3서식] <신설 2021. 12. 31.>
인도네시아와의 협정에 따른 원산지증명서의 서식
(앞쪽)
Certificate of Origin
ORIGINAL (Duplicate/Triplicate)

1. Exporter’s name and address: Reference No.:
KOREA-INDONESIA
COMPREHENSIVE
ECONOMIC PARTNERSHIP AGREEMENT
CERTIFICATE OF ORIGIN
2. Importer’s name and address: (Combined Declaration and Certificate)

FORM KI-CEPA

Issued in ___________ (Country)
(see Overleaf Notes)
3. Means of transport and route (as far as known): 4. Remarks:
Departure Date:
Vessel/Flight/Train/Vehicle No.:
Port of loading:
Port of discharge:

5. Item 6. Description of 7. HS code 8. Origin 9. Gross weight or 10. Number and
number goods(including (Six digit criterion other measurements date of invoice
number and type code) and FOB Value
of package, and (only when
quantity) RVC/QVC criterion is
used)

11. Declaration by the exporter: 12. Certification:

The undersigned hereby declares that the above It is hereby certified that the information herein is
details and statement are correct, that all the goods correct and that the goods described comply with the
were produced in origin requirements specified in the Korea-Indonesia
Comprehensive Economic Partnership Agreement.
……………………………………..
(Country)

and that they comply with the origin requirements
specified in the Korea-Indonesia Comprehensive
Economic Partnership Agreement for the goods
exported to
……………………………………..
(Importing Country)

…………………………………….. ……………………………………..
(Place and date,signature of authorized signatory) (Place and date, signature and stamp ofissuing body)

210mm×297mm[백상지(80g/㎡)

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