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19853911317

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1. Products consigned from (Exporter's business name, address, country) Reference No. 0004725/BJM/2024

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PT AMANAH COAL KALIMANTAN ASEAN-CHINA FREE TRADE AREA

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LE AMAN WORKSPACE DUTA MAS FATMAWATI BLOK D2 NO.9 PREFERENTIAL TARIFF
JL. RS FATMAWATI RAYA NO.39, CIPETE UTARA CERTIFICATE OF ORIGIN

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KEBAYORAN BARU, JAKARTA SELATAN DKI JAKARTA (Combined Declaration and Certificate)

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INDONESIA

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

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FORM E

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SHAANXI YULIN ENERGY GROUP COAL IMPORT AND EXPORT CO. LTD
Issued in INDONESIA
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NO.165 FUCHANG ROAD, FUGU TOWN, FUGU COUNTRY, YULIN CITY,
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SHAANXI PROVINCE, CHINA
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See Overleaf Notes
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3. Means of transport and route (as far as known) 4. For Official Use
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Departure Date SEPTEMBER 14, 2024
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Preferential Treatment Given
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Vessel's name/Aircraft etc. MV. TRISTAR DUGON
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Preferential Treatment Not Given (Please State reason/s)
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Port of Discharge YUHUAN
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Signature of Authorised Signatory of the Importing Party
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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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number of packages description of products (including (see Overleaf Notes) or net weight or date of Invoices
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quantity where appropriate other quantity and
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and HS number in six digit code) value (FOB) only
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when RVC
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criterion is applied
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1 NO MARK INDONESIAN STEAM COAL IN BULK WO 67,340.000 TNE 002/ACK/INV/IX/2024
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IN BULK SEPTEMBER 14, 2024
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HS: 270119
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11. Declaration by the exporter 12. Certification

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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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are correct; that all the products were produced in the exporter is correct.
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INDONESIA ISSUING OFFICE IN PROVINSI KALIMANTAN

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SELATAN
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(Country)
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and that they comply with the origin requirements specified for these
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Products in the Rules of Origin for the ACFTA for the products
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exported to
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CHINA
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(Importing Country)
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BANJARMASIN, SEPTEMBER 14, 2024

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Place and date, signature of authorized signatory

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13. Issued Retroactively Exhibition RIZKI ADHANI FADILA

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Movement Certificate Third Party Invoicing BANJARMASIN, SEPTEMBER 14, 2024

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Place and date, signature and stamp of certifying authority

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