Certificate of Origin

1. Exporter’s name, address, country:

Certificate No.:

CERTIFICATE OF ORIGIN

for China-Costa Rica Free Trade Agreement

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Issued in

(see Overleaf Instruction)

2. Producer’s name and address, if known:

3. Importer’s name, address, country:

For Official Use Only:

4. Means of transport and route (as far as known)

Departure Date:

Vessel /Flight/Train/Vehicle No.:

Port of loading:

Port of discharge:

5. Remarks:

6. Item

number

(Max. 20)

7. Marks and Numbers on packages

8. Number and kind of packages; Description of goods

9. HS code

(6 digit code)

10. Origin

criterion

11. Gross weight or other quantity (e.g. Quantity Unit, liters, m³.)

12. Number, date of invoice

and Invoiced value

13. Declaration by the exporter

The undersigned hereby declares that the above stated information is correct, and that all the goods are produced in

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(Country)

and that they comply with the origin requirements specified in the Free Trade Agreement for the goods exported to

（Importing country)

Place, date and signature of authorized person

14. Certification

On the basis of the carried out control, it is hereby certified that the information herein is correct and that the described goods comply with the origin requirements of the China -Costa Rica Free Trade Agreement.

Place and date[*], signature and stamp of the Authorized Body

Tel: Fax:

Address:

Overleaf Instruction

The English version of the Certificate of Origin shall be used and such Certificate shall be completed in that same language, in accordance with the overleaf instructions established herein.

Box 1

: State the full legal name, address of the exporter in China or

Costa Rica

Box 2

: State the full legal name, address (including country) of the producer. If more than one producer’s good is included in the certificate, list the additional producers, including name, address (including country). If the exporter or the producer wish the information to be confidential, state “Available to the competent authority or authorized body upon request”. If the producer and the exporter are the same, please complete the box with “SAME”. If the producer is unknown, state "UNKNOWN".

Box 3

: State the full legal name, address of the importer in China or

Costa Rica

Box 4

: Complete the means of transport and route and specify the departure date, transport vehicle No., port of loading and discharge, as far as known.

Box 5

: Customer’s Order Number, Letter of Credit Number, among others, may be included. If the invoice is issued by a non-Party operator, information such as name and country of the operator issuing the invoice shall be indicated herein.

Box 6

: State the item number, and item number shall not exceed 20. If the box’s space is not enough, additional pages, with the same form as the first page could be attached. Any additional page will have the phrase “page of ” noted, and the

boxes 6 to 14

will be completed with the corresponding information.

Box 7

: State the shipping marks and numbers on packages, when such marks and numbers exist, otherwise shall state “NO MARKS AND NUMBERS(N/M)”.

Box 8

: Number and kind of packages shall be specified. Provide a full description of each good. The description should be sufficiently detailed to enable the products to be identified by the Customs Officers examining them and relate it to the invoice description and to the HS description of the good. If goods are not packed, state “in bulk”. When the description of the goods is finished, add “***” (three stars) or “ \ ” (finishing slash).

Box 9

: For each good described in

Box 8

, identify the HS tariff classification to 6 digit code.

Box 10

: For each good described in

Box 8

, state which criterion is applicable, according to the following instructions. The rules of origin are contained in Chapter 4 (Rules of Origin and Related Operational Procedures) and Annex 3 (Product Specific Rules of Origin).

Origin Criterion