DRAFT - CERTIFICATE OF ORIGIN

1. Exporter (name, full address, country)

LIFTD DESIGN KSA LTD NEWTON HALL
TOWN STREET NEWTON CB22 7ZE See notes overleaf before completing this form.
UNITED KINGDOM
2. Certificate used in preferential trade between

3. Consignee (name, full address, country) (optional) United Kingdom

Dana Al Babtain 4244 Prince Saud Bin Fahd Bin
and
Abdulaziz Street
King Salman Bin Abdulaziz Rd Al ..............................................................................................................................................
Hezam Al Thahabie (Insert appropriate countries or groups of countries or territories)
Al Khobar 34432 Saudi Arabia
4. Country, group of countries or 5. Country, group of
territory in which the products are countriesor territory
considered as originating of destination
UK
6. Transport details (optional) 7. Remarks
BY SEA
FROM Bristol UK TO Dammam Port KSA
VIDE B/L NO MEDUIX259795
VESSEL NAME: MSC ATLANTIC III RL323R

(1) 8. Item number: marks and numbers Number and kind of packages (1): description of goods 9. Gross 10.
If weight Country
AS PER INVOICE
goods Gym Items as per order no. INV-0003 & INV-0001 (kg)or of Origin
are not HS CODE: 94036010 other
packed DESCRIPTION QTY DESCRIPTION QTY DESCRIPTION QTY measur
indicat e
Squat Rack 1.00 Med Ball Set 1.00 Adjustable Bench 1.00
e (litres,
Platform 1.00 Leg Platform 1.00 Custom Upholstery 1.00
numbe cu. m.)
Custom Steel Plate Sets 1.00 Chin/Dip Machine 1.00 Hex Dumbells 12.5-30kg 1.00
r of
articles Fractional Plates 1.00 Split Squat 1.00 hex DBs 1-10kg with vertical rack 1.00 6150.00 CFR
or Blkbox 15kg baR 1.00 Preacher Curl 1.00 TRX 1.00 KGS Bristol
state Open Hex Bar 1.00 Inverse Curl 1.00 Basecamp 4 Tier Storage Rack 1.00
Squat Rack - Inc Storage and United
‘in Safety bar 1.00 Spotter Arms 1.00 Kettlebell Set 8-24kg 1.00 Kingdom
bulk’, Custom Platform - Flush with
as Magnetic Bar collars 2.00 Floor 1.00 Med Ball Set 2/4/6/8/10 1.00

appropriate Curl Bar 1.00 Competition Bumper Plates 1.00 Hack Squat 1.00
Cable Attachment Set 1.00 Change Plates Set 1.00 Gym Extension / Curl 1.00
Landmine Station 1.00 15kg Bar 1.00 Theragun 1.00
Ab Mat 1.00 Hex Bar 1.00 Theragun Lower Back Bundle 1.00
Resistance Band Set 1.00 20kg Bar 1.00 Flooring 1.00
Exercise Mat 2.00 Magnetic Bar Collars 3.00 Sofa - Atlas 135CM (COM) 2.00
Chuchumber (Delano) Drum - Plain
Pull Top
Wall Mounted Mat Hanger 1.00 Curl Bar 1.00 Button (COM) 2.00
Ottoman - Azur Single with Storage
Lat Pulldown Attachment 1.00 cable Attachment set 1.00 (COM) 1.00
Ottoman - Azur Single with Storage
Adjustable Bench 1.00 Landmine attachment Set 1.00 (COM) 24.50
Custom Upholstery 1.00 Ab Mat 1.00 Fabric - 3 Beaches - Patterned 6.00
Custom Dumbells 6-30kg 1.00 Resistance Bands Set 1.00 Fabric - Pozzi Arturo - Fortezza 116 2.50
2 Tier Dumbell rack 1.00 exercise mat 2.00 DImensions 211x202x106cm 1.00
(2) TRX 1.00 Wall Mounted Mat Hanger 1.00
Complet Lat Pulldown Attachements Inc
Basecamp 4 Tier Storage Rack 1.00 Caribner Clip 1.00
e only
where
the
regulatio 11. Customs Endorsement 12. Declaration by the exporter
nsof the Declaration certified Stamp
exporting Export document (2):
countr I, the undersigned, declare that the goods described above
y or Form Number meet the conditions requiredfor the issue of this certificate.
territo
Customs office
ry Place and date
requir Issuing country or territory:
e UNITED KINGDOM
Signature
Date

Signature

C1299 1 HMRC 03/21

 13. Request for verification 14. Result of verification

To: Verification carried out shows that this certificate:

HM Revenue and Customs put ‘X’ in the appropriate box
Leeds Regional Centre
was issued by the Customs Office indicated and
7-8 Wellington Place
that the information contained therein is accurate
Wellington Street
Leeds
LS1 4AP does not meet the requirements as to authenticity
ENGLAND and accuracy (see remarks appended)

Verification of the authenticity and accuracy of this

certificate is requested.

Place and date Place and date

Signature Signature

Stamp Stamp

Notes
1. Certificate must not contain erasures or words written over one another. Any alterations must be made by deleting
the incorrect particulars and adding any necessary corrections. Any such alteration must be initialled by the
person who completed the certificate and endorsed by the Customs authorities of the issuing country or territory.

2. No spaces must be left between the items entered on the certificate and each item must be preceded by an item
number. A horizontal line must be drawn immediately below the last item. Any unused space must be struck
through in such a manner as to make any later additions impossible.

3. Goods must be described in accordance with commercial practice and with sufficient detail to allow them to
be identified.

2
 DRAFT - CERTIFICATE OF ORIGIN
1. Exporter (name, full address, country)
LIFTD DESIGN KSA LTD NEWTON HALL
TOWN STREET NEWTON CB22 7ZE See notes overleaf before completing this form.
UNITED KINGDOM
2. Certificate used in preferential trade between

3. Consignee (name, full address, country) (optional) United Kingdom

Dana Al Babtain 4244 Prince Saud Bin Fahd Bin
and
Abdulaziz Street
King Salman Bin Abdulaziz Rd Al ..............................................................................................................................................
Hezam Al Thahabie (Insert appropriate countries or groups of countries or territories)
Al Khobar 34432 Saudi Arabia
4. Country, group of countries or 5. Country, group of
territory in which the products are countriesor territory
considered as originating of destination
UK
6. Transport details (optional) 7. Remarks
BY SEA
FROM Bristol UK TO Dammam Port KSA
VIDE B/L NO MEDUIX259795
VESSEL NAME: MSC ATLANTIC III RL323R

(1) 8. Item number: marks and numbers Number and kind of packages (1): description of goods 9. Gross 10.
If goods weight Country of
AS PER INVOICE
are not Gym Items as per order no. INV-0003 & INV-0001 (kg)or Origin
packed HS CODE: 94036010 other
indicate measu
DESCRIPTION QTY DESCRIPTION QTY DESCRIPTION QTY
number re
Squat Rack 1.00 Med Ball Set 1.00 Adjustable Bench 1.00
of articles (litres,
Platform 1.00 Leg Platform 1.00 Custom Upholstery 1.00
or state cu. m.)
‘in bulk’, Custom Steel Plate Sets 1.00 Chin/Dip Machine 1.00 Hex Dumbells 12.5-30kg 1.00

as Fractional Plates 1.00 Split Squat 1.00 hex DBs 1-10kg with vertical rack 1.00

appropriate Blkbox 15kg baR 1.00 Preacher Curl 1.00 TRX 1.00
Open Hex Bar 1.00 Inverse Curl 1.00 Basecamp 4 Tier Storage Rack 1.00
Squat Rack - Inc Storage and 6150.00 CFR Bristol
Safety bar 1.00 Spotter Arms 1.00 Kettlebell Set 8-24kg 1.00
Custom Platform - Flush with
KGS United
Magnetic Bar collars 2.00 Floor 1.00 Med Ball Set 2/4/6/8/10 1.00 Kingdom
Curl Bar 1.00 Competition Bumper Plates 1.00 Hack Squat 1.00
Cable Attachment Set 1.00 Change Plates Set 1.00 Gym Extension / Curl 1.00
Landmine Station 1.00 15kg Bar 1.00 Theragun 1.00
Ab Mat 1.00 Hex Bar 1.00 Theragun Lower Back Bundle 1.00
Resistance Band Set 1.00 20kg Bar 1.00 Flooring 1.00
Exercise Mat 2.00 Magnetic Bar Collars 3.00 Sofa - Atlas 135CM (COM) 2.00
Chuchumber (Delano) Drum - Plain
Pull Top
Wall Mounted Mat Hanger 1.00 Curl Bar 1.00 Button (COM) 2.00
Ottoman - Azur Single with Storage
Lat Pulldown Attachment 1.00 cable Attachment set 1.00 (COM) 1.00
Ottoman - Azur Single with Storage
Adjustable Bench 1.00 Landmine attachment Set 1.00 (COM) 24.50
Custom Upholstery 1.00 Ab Mat 1.00 Fabric - 3 Beaches - Patterned 6.00
Custom Dumbells 6-30kg 1.00 Resistance Bands Set 1.00 Fabric - Pozzi Arturo - Fortezza 116 2.50
2 Tier Dumbell rack 1.00 exercise mat 2.00 DImensions 211x202x106cm 1.00
TRX 1.00 Wall Mounted Mat Hanger 1.00
Lat Pulldown Attachements Inc
Basecamp 4 Tier Storage Rack 1.00 Caribner Clip 1.00

(2) 11. Customs Endorsement 12. Declaration by the exporter

Complete Declaration certified Stamp
only where Export document (2):
the I, the undersigned, declare that the goods
regulations Form Number described above meet the conditions required
of the for the issue of this certificate.
exporting Customs office
country Issuing country or territory: Place and date
or UNITED KINGDOM
territory
require Date Signature

Signature

C1299 3
The conditions under which a movement certificate EUR1 may be issued are specified in the relevant Protocol concerning the
definition of originating products annexed to the preferential trade agreements between the UK and the country/countries or
groups of countries or territories named in box 2 overleaf.

Penalties for providing untrue information

It is an offence under the Customs and Excise Management Act 1979, Section 167, to provide, or cause to be provided, untrue
information or evidence to an officer of HM Revenue and Customs. Accordingly, any person who does so in support of an
application for the issue of a movement certificate, or in the course of any subsequent verification, may be liable to penalties.

Complaints

The Adjudicator reviews complaints not settled to your satisfaction by HM Revenue and Customs. The recommendations of the
Adjudicator are independent and the service is free. The Adjudicator only looks at complaints, not general enquiries. Phone the
Adjudicator on 0300 057 1111 or go to their website www.adjudicatorsoffice.gov.uk

Declaration by the exporter only

I, the undersigned, exporter of the goods described overleaf, have read the relevant guidance and:

1. Declare that these goods meet the conditions required for the issue of the attached certificate

2. Specify as follows the circumstances which have allowed these goods to meet the above conditions

3. Submit the following supporting documents

4. Undertake to submit, at the request of an officer of HM Revenue and Customs, any supporting evidence which the officer may
require for the purpose of issuing the attached certificate, and undertake, if required, to agree to any inspection of my
accounts, and any check on the processes of manufacture of the above goods, carried out by the said officer of
HM Revenue and Customs.

5.
C1444 issued date stamp

Place ...................................................................................................... Date ............................................................

Signature .......................................................................................................................................................................

Name (in capital letters) .....................................................................................................................................

Status of signatory .................................................................................................................................................

Company name .........................................................................................................................................................