ETHIOPIAN CUSTOMS

COMMISSION
DECLARATION FORM
2021 / NAZ00 / 4 / 693 1 DECLARATION A. CLEARANCE OFFICE ADAMA
2 Consignor/Exporter No Office Code Manifest Number
WABE GROUP FZCO. DJIBOUTI. IM 4 NAZ00

3 Forms 4 Loading Lists Registration number & date Assessment number & date
1 1 4-000693 31/03/2021 A-002170 31/03/2021
5 Items 6 Tot. Pkgs. 7 Declarant Reference number Receipt number & date
1 5400 2021 / IM0016 R-001710 31/03/2021
8 Consignee/Importer No 0017004845 No 10 Country of Last
9 Person responsible for financial settlement
ALIYOW DUBE ALIYOW DJ Consign.
AR/AA/05/3201110/4301997/2013
SOMALI 11 Trading

country
15 Country of dispatch/export 15 C. disp./exp. code 17 Country destin. code

Djibouti a DJ b a ET b SM
14 Declarant No 0071952990 16 Country of origin 17 Country of destination Section
BEKA CUSTUM TRANSIT PLC India Ethiopia CG
OROMIYA
ADAMA 20. Delivery Terms Business Activity
FOB 02
18 Identity and nationality of means of transport at arrival 19 Ctr. 22 Currency and total amount invoiced 23 Exchange rate 24 Nature of
GLOBAL TRANSIT USD 1,000.00 41.4094 transactio
21 Identity and nationality of active means of transport crossing the border 28 Financial and banking data 24 Invoice Details
Bank Code Currency Amount
Ex. Freight ETB 2,070.00
25 Mode of transport 26 Inland mode 27 Place of Loading
at the border of transport
Branch Terms of Payment Insurance ETB 828.00
61 3 Djibouti DJJIB
0 FRANCO Other ETB 2,070.00
29 Office of entry/exit 30 Location of goods
B. P. number and date In. Freight ETB 0.00
GAL00 GALAFI (GAL) Total ETB 4,968.00
31 Packages Marks & 32 Item 33 Commodity Code
and numbers 1 No 17011400 000 0000 0000
description
of goods Number & kind of packages 34 Country of origin Code 35 Gross Mass (kg) 36 Preference
Ctr.
No(s) 5400 BG Bag a IN b 271000
Description of goods 42 a 37 PROCEDURE 38 Net mass (kg) 39 Quota
--OTHER CANE SUGAR Ex. Freight 2,070.00 4000 000 270000
WHITE CRYISTAL SUGAR INDIA AND BRAZIL 50kg Insurance 828.00 40 Summary declaration/Previous document / Way bill
Other Costs 2,070.00
In. Freight 0.00
41 Supplementary units 42 Item price 43 V.M.

44 Additional 1,000.00 Code

License number Deducted Quantity Deducted Value
Information/ A.I. Code 45 Adjustment
Produced
documents Attached document codes 1
001 004 005 006 320 007 016 46 Statistical Value
Proc. Program
46,377.00
Type Duty/Tax Base Rate Amount MP 48 Account No / Deferred Payment 49 Warehouse code / period
47 Taxes &
duties 01 46,377.00 5 2,318.85 1
03 48,696.00 0 0.00 1 Summary of Payables
04 48,696.00 15 7,304.40 1 Amount

05 56,000.00 0 0.00 1 Total duties & taxes 11,047.02

15 46,377.00 3 1,391.31 1 Guarantee amount 0.00
16 46,377.00 0.07 32.46 1 Total fees 0.00
Other 0.00
Total Payable 11,047.02
Total 11,047.02 1
50 Declaration C OFFICE OF DEPARTURE

I, DEBELO KAJELA ARARSO (AG1863), the undersigned of BEKA CUSTUM TRANSIT PLC OROMIYA
ADAMA do hereby declare that the information and particulars declared are true and complete and accept
fully the condition and requirements attaching to the use of CPC declared here in and hold myself liable for
any inaccurate information.

Signature Date & stamp Address

52 Guarantee Code 53 Office of destination (and country)

not valid for

D CONTROL BY OFFICE OF DEPARTURE Stamp: 54 Place and date:

Result:

Seals affixed: Number:

Signature and name of declarant/representative
Identity:
DEBELO KAJELA ARARSO (AG1863)
Time limit (date):

Signature: