Statement on origin

(Period: from ___________ to ___________ (1))

The exporter of the products covered by this document (Exporter Reference No ...(2)) declares that, except where otherwise clearly indicated, these products are of Union preferential origin.

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(4) (Place and date)

(Name of the exporter)

(1) If the statement on origin is completed for multiple shipments of identical originating products within the meaning of point (b) of Article 56(4) of this Agreement, indicate the period for which the statement on origin is to apply. That period shall not exceed 12 months. All importations of the product must occur within the period indicated. If a period is not applicable, the field may be left blank.

(2) Indicate the reference number by which the exporter is identified. For the Union exporter, this will be the number assigned in accordance with the laws and regulations of the Union. For the United Kingdom exporter, this will be the number assigned in accordance with the laws and regulations applicable within the United Kingdom. Where the exporter has not been assigned a number, this field may be left blank.

(3) Indicate the origin of the product: the United Kingdom or the Union.

(4) Place and date may be omitted if the information is contained on the document itself.