■ 자유무역협정의 이행을 위한 관세법의 특례에 관한 법률 시행규칙 [별지 제24호의4서식] <신설 2021. 12. 31.>
인도네시아와의 협정에 따른 원산지증명서의 서식(을지)
Certificate of Origin (Additional Pages)
ORIGINAL (Duplicate/Triplicate)
Reference No.
5. Item number	6. Description of goods(including number and type of package, and quantity)	7. HS code (Six digit code)	8. Origin criterion		9. Gross weight or other measurements and FOB Value (only when RVC/QVC criterion is used)	10. Number and date of invoice
11. Declaration by the exporter: The undersigned hereby declares that the above details and statement are correct, that all the goods were produced in …………………………………….. (Country) and that they comply with the origin requirements specified in the KICEPA for the goods exported to …………………………………….. (Importing Country) …………………………………….. Place and date, signature of authorized signatory				12. Certification: It is hereby certified that the information herein is correct and that the goods described comply with the origin requirements specified in the Korea-Indonesia CEPA. …………………………………….. Place and date, signature and stamp of issuing body
210mm×297mm[백상지 80g/㎡(재활용품)]