FORM F SAMPLE

1. Exporter’s name, address, country: Certificate N°: CERTIFICATE OF ORIGIN 2. Producer’s name and address, if Form F for China-Chile FTA know: Isued in_____________ 3. Consignee’s name, address, country: 4. Means of transport and route (as far as know) Departure Date: Vessel/Flight/Train/Vehicle N°: Port of loading: Port of discharge: 7. Item 8. Marks number and (Max 20) numbers on packages 9. Number and kind of packages; description of goods 10. HS code (Six digit code) 5. For Official Use Only Preferential Tariff Treatment Given Under_______ Preferential Treatment Not Given (Please state reasons) ------------------------------------------------------ Signature of Authorized Signatory of the Importing Country 6. Remarks 11. Origin criterion 12. Gross weight, quantity (Quantity Unit) or other measures (liters, m3, etc) 13. Number, date of invoices and invoiced value 14. 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 FTA for the goods exported to (Importing country) Place and date, signature of authorized signatory 15. Certification It is hereby certified, on the basis of control carried out, that the declaration of the exporter is correct. Place and date, signature and stamp of certifying authority Certifying authority Tel: Fax: Address:

INSTRUCTIONS TO FILL THE ABOVE CERTIFICATE

 Box 1: State the full legal name, address (including country) of the exporter.

 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 wishes the information to be confidential, it is acceptable to state “Available to the competent governmental authority upon request”. If the producer and the exporter are the same, please complete field with “SAME”. If the producer is unknown, it is acceptable to state \"UNKNOWN\".

 Box 3: State the full legal name, address (including country) of the consignee.

 Box 4: Complete the means of transport and route and specify the departure date, transport vehicle No., port of loading and discharge.

 Box 5: The customs authorities of the importing country must indicate (√ ) in the relevant boxes whether or not preferential tariff treatment is accorded.

 Box 6: Customer’s Order Number, Letter of Credit Number, and etc. may be included if required. If the invoice is issued by a non-Party operator, the name, address of the producer in the originating Party shall be stated herein.

 Box 7: State the item number, and item number should not exceed 20.  Box 8: State the shipping marks and numbers on the packages.

 Box 9: Number and kind of package 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 10: For each good described in Box 9, identify the HS tariff classification to six digits.

 Box 11: If the goods qualify under the Rules of Origin, the exporter must indicate in Box 11 of this form the origin criteria on the basis of which he claims that his goods qualify for preferential tariff treatment, in the manner shown in the following table: The origin criteria on the basis of which the exporter claims that his goods qualify for preferential tariff treatment Goods wholly obtained General rule as ≥40% regional value content Products specific rules Insert in Box 11 P RVC PSR

 Box 12: Gross weight in Kilos should be shown here. Other units of measurement e.g. volume or number of items which would indicate exact quantities may be used when customary.

 Box 13: Invoice number, date of invoices and invoiced value should be shown here.

 Box 14: The field must be completed, signed and dated by the exporter. Insert the place, date of signature.

 Box 15: The field must be completed, signed, dated and stamped by the authorized person of the certifying authority. The telephone number, fax and address of the certifying authority shall be given.

END