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PETAMBURAN, KOTA ADM. JAKARTA BARAT, DKI JAKARTA CERTIFICATE OF ORIGIN

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Page 2 / 5
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1. Products consigned from (Exporter's business name, address, country) Reference No. 0008492/TGR/2025

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PT TORABIKA EKA SEMESTA ASEAN-CHINA FREE TRADE AREA

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GEDUNG MAYORA JL. TOMANG RAYA NO. 21-23, TOMANG, GROGOL PREFERENTIAL TARIFF
PETAMBURAN, KOTA ADM. JAKARTA BARAT, DKI JAKARTA CERTIFICATE OF ORIGIN

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MAYORA FOOD (SHANGHAI)CO.,LTD.
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5. Item 6. Marks and numbers 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number,
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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
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Page 3 / 5
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1. Products consigned from (Exporter's business name, address, country) Reference No. 0008492/TGR/2025

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PT TORABIKA EKA SEMESTA ASEAN-CHINA FREE TRADE AREA

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GEDUNG MAYORA JL. TOMANG RAYA NO. 21-23, TOMANG, GROGOL PREFERENTIAL TARIFF
PETAMBURAN, KOTA ADM. JAKARTA BARAT, DKI JAKARTA CERTIFICATE OF ORIGIN

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KOPIKO VOLCANIC BLACK COFFEE 662.800 KGM FEBRUARY 21, 2025
to ala

to ala

to ala
48X12X2G (SIX HUNDRED SIXTY
d

d
ai

ai

ai
us kan

us kan

us kan
cl

cl

cl
CIF/CNY : 33,600.00 TWO POINT EIGHT)
e-

e-

e-
CNY 33,530.890
be na

be na

be na
ed

ed

ed
NW : 230.40 KGM
ot igu

ot igu

ot igu
d

d
ca dak

ca dak

ca dak
CIF SHANGHAI
i

i
it

it

it
nn

nn

nn
in

in

in
HS : 21011200
n

n
ka

ka

ka
e

e
at

at

at
ta

ta

ta
pl

pl

pl
ce

ce

ce
m

m
te

te

te
uk

uk

uk
HS: 210112
d

d
nt

nt

nt
te

te

te
Be

Be

Be
in

in

in
pr

pr

pr
5 300 CT WO GW: 10250200307
is

is

is
KOPIKO VOLCANIC BLACK COFFEE 780.000 KGM FEBRUARY 21, 2025
Th

Th

Th
24X25X2G (SEVEN HUNDRED
CIF/CNY : 48,600.00 EIGHTY)
tm si.

tm si.

CNY 48,517.080
ea en

ea en
t.

t.
en

en
Tr er

Tr er

NW : 360.00 KGM
iff ref

iff ref
p

CIF SHANGHAI
l T arif

l T arif
t

t
en laim

en laim
ar

ar

HS : 21011200
ef s k

ef s k
tia

tia
Pr se

Pr se
rm

rm

rm
m pro

m pro
er

er

m pr
HS: 210112
m

m
Fo

Fo

Fo
to ala

to ala

to ala
d

d
ai

ai

ai
us kan

us kan

us kan
cl

cl

cl
e-

e-

e-
be na

be na

be na

11. Declaration by the exporter 12. Certification

ed

ed

ed
ot igu

ot igu

ot igu

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
d

are correct; that all the products were produced in the exporter is correct.
ca dak

ca dak

ca dak
i

i
at ni t

at ni t

at ni t
nn

nn

nn
i

INDONESIA ISSUING OFFICE IN KABUPATEN TANGERANG

n

n
te ka

te ka

te ka
e

e
a

(Country)
pl

pl

pl
te cet

et

te cet
m

m
in k c

and that they comply with the origin requirements specified for these
pr tuk

pr tuk
tu
d

Products in the Rules of Origin for the ACFTA for the products
n

n
te
Be

Be

Be

exported to
in

in
pr
is

is

is
Th

Th

Th

CHINA
tm si.

tm si.

(Importing Country)
ea en

ea en
t.

t.
en

en
Tr er

Tr er
iff ref

iff ref
p

KOTA ADM. JAKARTA BARAT, MARCH 03, 2025

l T arif

l T arif
t

Place and date, signature of authorized signatory

en laim

en laim
ar

ar
ef s k

ef s k
tia

tia

13. Issued Retroactively Exhibition SYAMSUL ARIF HIDAYAT

Pr se

Pr se
rm

rm

rm
m pro

m pro
er

er

Movement Certificate Third Party Invoicing TANGERANG, MARCH 03, 2025

m pr
m

m
Fo

Fo

Fo
to ala

to ala

to ala

Place and date, signature and stamp of certifying authority

d

d
ai

ai

ai
us kan

us kan

us kan
cl

cl

cl

Page 4 / 5
e-

e-

e-
na

na

na
ed

ed

ed
gu

gu

gu
di

di

di
e

e
k

k
tb

tb

tb
da

da

da
 tm si.

tm si.
ea en

ea en
t.

t.
en

en
25583460632

Tr er

Tr er
iff ref

iff ref
1. Products consigned from (Exporter's business name, address, country) Reference No. 0008492/TGR/2025

p
l T arif

l T arif
PT TORABIKA EKA SEMESTA ASEAN-CHINA FREE TRADE AREA

t
en laim

en laim
ar

ar
GEDUNG MAYORA JL. TOMANG RAYA NO. 21-23, TOMANG, GROGOL PREFERENTIAL TARIFF
PETAMBURAN, KOTA ADM. JAKARTA BARAT, DKI JAKARTA CERTIFICATE OF ORIGIN

ef s k

ef s k
tia

tia
INDONESIA (Combined Declaration and Certificate)

Pr se

Pr se
m

m
m pro

m pro
er

er

m pr
or

or

or
2. Goods consigned to (Consignee's name, address, country)

m
FORM E

to ala

to ala

to ala
F

F
d

d
ai

ai

ai
MAYORA FOOD (SHANGHAI)CO.,LTD.
Issued in INDONESIA
us kan

us kan

us kan
cl

cl

cl
2888 HUNAN ROAD, KANGQIAOZHEN,
e-

e-

e-
be na

be na

be na
NANHUI DISTRICT,
ed

ed

ed
ot igu

ot igu

ot igu
SHANGHAI – CHINA See Overleaf Notes
d

d
ca dak

ca dak

ca dak
i

i
at ni t

at ni t

at ni t
nn

nn

nn
3. Means of transport and route (as far as known) 4. For Official Use
i

i
n

n
te ka

te ka

te ka
e

e
Departure Date MARCH 02, 2025
a

a
pl

pl

pl
te cet

te cet

te cet
Preferential Treatment Given
m

m
uk

uk

uk
d

d
nt

nt

nt
Be

Be

Be
Vessel's name/Aircraft etc. XIN YAN TAI / 254N
in

in

in
Preferential Treatment Not Given (Please State reason/s)
pr

pr

pr
s

s
i

i
Th

Th

Th
Port of Discharge SHANGHAI
tm si.

tm si.
Signature of Authorised Signatory of the Importing Party
ea en

ea en
t.

t.
en

en
Tr er

Tr er
iff ref

iff ref
5. Item 6. Marks and numbers 7. Number and type of packages, 8. Origin criteria 9. Gross weight 10. Number,
p

p
l T arif

l T arif
number of packages description of products (including (see Overleaf Notes) or net weight or date of Invoices
t

t
quantity where appropriate other quantity and
en laim

en laim
ar

ar
and HS number in six digit code) value (FOB) only
ef s k

ef s k
tia

tia
when RVC
Pr se

Pr se
rm

rm

rm
criterion is applied
m pro

m pro
er

er

m pr
6 30 CT WO GW: 10250200307
m

m
Fo

Fo

Fo
KOPIKO WHITE COFFEE 20X20X30G 419.400 KGM FEBRUARY 21, 2025
to ala

to ala

to ala
CIF/CNY : 6,900.00 (FOUR HUNDRED
d

d
ai

ai

ai
us kan

us kan

us kan
cl

cl

cl
NINETEEN POINT
e-

e-

e-
NW : 360.00 KGM FOUR)
be na

be na

be na
ed

ed

ed
CNY 6,879.970
ot igu

ot igu

ot igu
CIF SHANGHAI
d

d
ca dak

ca dak

ca dak
HS : 21011200
i

i
it

it

it
nn

nn

nn
in

in

in
n

n
SAY TOTAL : 1,780 CARTONS
ka

ka

ka
e

e
at

at

at
ta

ta

ta
pl

pl

pl
ce

ce

ce
m

m
1 X 40 HC CONTAINER
te

te

te
uk

uk

uk
d

d
nt

nt

nt
te

te

te
Be

Be

Be
in

in

in
pr

pr

pr
HS: 210112
is

is

is
Th

Th

Th
tm si.

tm si.
ea en

ea en
t.

t.
en

en
Tr er

Tr er
iff ref

iff ref
p

p
l T arif

l T arif
t

t
en laim

en laim
ar

ar
ef s k

ef s k
tia

tia
Pr se

Pr se
rm

rm

rm
m pro

m pro
er

er

m pr
m

m
Fo

Fo

Fo
to ala

to ala

to ala
d

d
ai

ai

ai
us kan

us kan

us kan
cl

cl

cl
e-

e-

e-
be na

be na

be na

11. Declaration by the exporter 12. Certification

ed

ed

ed
ot igu

ot igu

ot igu

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
d

are correct; that all the products were produced in the exporter is correct.
ca dak

ca dak

ca dak
i

i
at ni t

at ni t

at ni t
nn

nn

nn
i

INDONESIA ISSUING OFFICE IN KABUPATEN TANGERANG

n

n
te ka

te ka

te ka
e

e
a

(Country)
pl

pl

pl
te cet

et

te cet
m

m
in k c

and that they comply with the origin requirements specified for these
pr tuk

pr tuk
tu
d

Products in the Rules of Origin for the ACFTA for the products
n

n
te
Be

Be

Be

exported to
in

in
pr
is

is

is
Th

Th

Th

CHINA
tm si.

tm si.

(Importing Country)
ea en

ea en
t.

t.
en

en
Tr er

Tr er
iff ref

iff ref
p

KOTA ADM. JAKARTA BARAT, MARCH 03, 2025

l T arif

l T arif
t

Place and date, signature of authorized signatory

en laim

en laim
ar

ar
ef s k

ef s k
tia

tia

13. Issued Retroactively Exhibition SYAMSUL ARIF HIDAYAT

Pr se

Pr se
rm

rm

rm
m pro

m pro
er

er

Movement Certificate Third Party Invoicing TANGERANG, MARCH 03, 2025

m pr
m

m
Fo

Fo

Fo
to ala

to ala

to ala

Place and date, signature and stamp of certifying authority

d

d
ai

ai

ai
us kan

us kan

us kan
cl

cl

cl

Page 5 / 5
e-

e-

e-
na

na

na
ed

ed

ed
gu

gu

gu
di

di

di
e

e
k

k
tb

tb

tb
da

da

da