1.

Exporter's name, address and country Number of page

PT HANYOUNG ELECTRONIC INDONESIA Certification No.
JL. JANGARI RT.03 RW.02, HEGARMANAH, SUKALUYU,
CIANJUR, JAWA BARAT Page 1 / 1
INDONESIA

AGREEMENT BETWEEN THE REPUBLIC OF INDONESIA

2. Importer’s name, address, and country
JAPAN AND JAPAN FOR AN ECONOMIC PARTNERSHIP
OSAKA JAPAN
JAPAN

CERTIFICATE OF ORIGIN
FORM IJEPA
3. Means of transport and route (as far as known)
SHIPPED BY : KMTC ABSD 1234N

FROM : TANJUNG PRIOK

TO : OSAKA
Issued in INDONESIA
DATE OF SHIPMENT : OCTOBER 27, 2023 See notes overleaf
4. Item number (as necessary); marks and numbers of packages; number 5. Preference 6. Quantity or weight 7. Invoice
and kind of package; description of good(s); HS tariff classification number Criterion number(s) and
date(s)

8. Remarks

9. Declaration by the exporter 10. Certification

I, undersigned, declare that
- the above details and statement are true and accurate
- the good(s) described above meet the condition(s) required for the
issuance of this certificate
- the country of origin of the good(s) described above is INDONESIA
It is hereby certified, on the basis of control carried out that the
declaration by exporter is correct.
Component govermental authority or designee office
ISSUING OFFICE IN KOTA SUKABUMI

Place and date CIANJUR,

Stamp

Signature

Name (printed) SUNG KI HO

Place and date SUKABUMI,
Company PT HANYOUNG ELECTRONIC INDONESIA
Signature