116673335101

1. Goods consigned from ( exporter's business name, address, Reference No. 0000408/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : CONTI DARWIN 141N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : ONTARIO

DATE OF : OCTOBER 24, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
1 MADE IN INDONESIA 375 CT W 9503 1,500 PCE 424/EXP.LBJ/102
TOTAL : 507 PO NO.: L-4055358 950300 1,548.75 KGM 1
CARTONS DISNEY ITEM : 400916215251 OCTOBER 16,
SUPPLIER STYLE NO.: 020S320U020 2021
ACC20 AVN CAMPUS FIG SET
1500 PCS / 375 CT

2 7 CT W 9608 672 PCE 424/EXP.LBJ/102

PO NO.: L-4943222 960810 187.6 KGM 1
DISNEY ITEM : 400941265375 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q122U007 2021
STAT122 FIGPEN CHEWY
672 PCS / 7 CT

3 49 CT W 9608 4,704 PCE 424/EXP.LBJ/102

PO NO.: L-4233404 960810 295.47 KGM 1
DISNEY ITEM : 400932913384 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q321U030 2021
STAT321 PEN GROOT
4704 PCS / 49 CT

4 9 CT W 9608 864 PCE 424/EXP.LBJ/102

PO NO.: L-4059698 960810 87.1 KGM 1
DISNEY ITEM : 400932913360 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q321U027 2021
STAT321 PEN ARIEL
864 PCS / 9 CT

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 13, 2022 GRESIK, JANUARY 13, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 1 / 3
 116673335101

1. Goods consigned from ( exporter's business name, address, Reference No. 0000408/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : CONTI DARWIN 141N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : ONTARIO

DATE OF : OCTOBER 24, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
5 9 CT W 9608 864 PCE 424/EXP.LBJ/102
PO NO.: L-4059698 960810 87.1 KGM 1
DISNEY ITEM : 400932913377 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q321U028 2021
STAT321 PEN BELLE
864 PCS / 9 CT

6 13 CT W 9503 1,248 PCE 424/EXP.LBJ/102

PO NO.: L-4059698 960810 78.39 KGM 1
DISNEY ITEM : 400932913384 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q321U030 2021
STAT321 PEN GROOT
1248 PCS / 13 CT

7 9 CT W 9608 864 PCE 424/EXP.LBJ/102

PO NO.: L-4059698 960810 107.1 KGM 1
DISNEY ITEM : 400932913391 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q321U031 2021
STAT321 PEN DVADER
864 PCS / 9 CT

8 9 CT W 9608 864 PCE 424/EXP.LBJ/102

PO NO.: L-4059698 960810 152.64 KGM 1
DISNEY ITEM : 400941265344 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q122U004 2021
STAT122 FIGPEN BEAST
864 PCS / 9 CT

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 13, 2022 GRESIK, JANUARY 13, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 2 / 3
 116673335101

1. Goods consigned from ( exporter's business name, address, Reference No. 0000408/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : CONTI DARWIN 141N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : ONTARIO

DATE OF : OCTOBER 24, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
9 9 CT W 9608 864 PCE 424/EXP.LBJ/102
PO NO.: L-4059698 960810 118.98 KGM 1
DISNEY ITEM : 400941265351 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q122U005 2021
STAT122 FIGPEN BUZZ
864 PCS / 9 CT

10 9 CT W 9608 864 PCE 424/EXP.LBJ/102

PO NO.: L-4059698 960810 90.27 KGM 1
DISNEY ITEM : 400941265368 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q122U006 2021
STAT122 FIGPEN SALLY
864 PCS / 9 CT

11 9 CT W 9608 864 PCE 424/EXP.LBJ/102

PO NO.: L-4059698 960810 241.2 KGM 1
DISNEY ITEM : 400941265375 OCTOBER 16,
SUPPLIER STYLE NO.: 050Q122U007 2021
STAT122 FIGPEN CHEWY
864 PCS / 9 CT

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 13, 2022 GRESIK, JANUARY 13, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 3 / 3