ANNEX I [1]

Supplier's declaration (for single use) for products having preferential origin status

I, the undersigned, declare that the goods listed on this document …………………………… (1)

originate in …………………………… (2) and satisfy the rules of origin governing preferential

trade with


EEA ( NO / LI / IS / )

CH / TR / AD /
XC / XL / TN / MA / DZ / EG / JO / IL / PS / LB / SY / FO /
MK / BA / XS / ME / XK / AL /
MD /

KR /

ZA /

MX / CL /
Andes ( PE / CO / )
Central-America ( CR / SV / GT / HN / NI / PA / )
Cariforum ( AG / BS / BB / BZ / DM / DO / GD / GY / JM / KN / LC / VC / SR / TT / )
ESA (MG / MU / SC / ZW / )

West Pacific (PG / )
OCT* / GSP* / MAR-ACP*

I declare that:

� Cumulation applied with …………. (name of the country/countries) (4)

� No cumulation applied

I undertake to make available to the customs authorities any further supporting documents they require:

Name and function: Place and date:
………………………………. ………………………

Name and address of the company: Signature:
………………………………. ………………………
Stamp of the company:
……………………………….


Take over the text on the first page – after completion – on company letter paper.

Directions for completion:

(1)  Number and date of the sales invoice, the delivery note of the packing list

(2)  The European Union, country, group of countries or territory in which / where the goods originate.
For products originating in the European Union, "European Union" must be entered. If abbreviations should be used, please use the following code: 'EU'. In addition, the specification of an EU Member State (for example, Germany or France) may take place when the goods have been produced there. In the case of goods originating in a country with which the EU has preferential agreements (e.g., Switzerland, South Africa, etc.), this country needs to be specified. Within

-  The pan-European cumulation zone – includes the EU Member States, Iceland, Liechtenstein, Norway, Switzerland and Turkey or

-  The Pan-Euro-Med cumulation zone – includes the EU countries, Algeria, Egypt, Faroe Islands, Iceland, Israel, Jordan, Lebanon, Liechtenstein, Morocco, Norway, occupied Palestinian territory, Switzerland, Syria, Turkey and Tunisia or

-  SAP cumulation zone (Stabilization and Association process zone) – includes the EU member states, Albania, Bosnia and Herzegovina, Macedonia, Montenegro, Serbia and Turkey, these can also be called countries of origin.

(3)  Country, group of countries or territory:

EEA - Norway, Iceland and Liechtenstein

ACP / MAR* - African-Caribbean-Pacific (ACP) / Market Access Regulation (MAR)

Cariforum - Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Dominican Republic, Grenada, Guyana, Jamaica, Saint Christopher and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, Trinidad and Tobago

Pacific - Fiji (FJ) – suspended – and Papua New Guinea (PG) already in force

Central - Costa Rica (CR), El Salvador (SV), Guatemala (GT),

America Honduras (HN), Nicaragua (NI), Panama (PA)

ESA - states of Eastern and Southern Africa: Comoros (KM) – not yet implemented – Madagascar (MG) Mauritius (MU) Seychelles (SC) Zambia (ZM) – not yet implemented – Zimbabwe (ZW)

OCT* - Overseas Countries and Territories of the EU Member States

GSP* - Generalized System of Preferences – developing countries

* For an actual overview of this countries please contact the Chamber of Commerce

(4)  To be completed only for goods having preferential origin status in the context of preferential trade relations with one of the countries referred to in Articles 3 and 4 of the relevant origin Protocol, with which Pan-Euro-Mediterranean cumulation of origin is applicable.

NO / CH / IS / LI / FO / MK / BA / XS / ME / AL /
XC / XL / TN / MA / DZ / EG / JO / IL / PS / LB / SY / TR

[1] Regulation (EC) Nr. 1207/2001 of the Council of 11 June 2001; Official J. L 165 of 21.6.2001, p. 1 ; amended by Regulation (EC) Nr. 1617/2006 of the Council of 24 October 2006; Official J. L 300 of 31.10.2006, p. 5.