ANNEX 3-D

TEXT OF THE STATEMENT ON ORIGIN

A statement on origin shall be made out using the text set out below in one of the following
linguistic versions and in accordance with the laws and regulations of the exporting Party. If thestatement on origin is handwritten, it shall be written in ink in printed characters. The statement onorigin shall be drawn up in accordance with the respective footnotes. The footnotes do not have tobe reproduced.

Japanese version（期間……………から……………まで（注１））

この文書の対象となる産品の輸出者（輸出者参照番号………（注２））は、別段の明示をする場合を除くほか、当該産品の原産地………（注３）が特恵に係る原産地であることを申告する。

（用いられた原産性の基準（注４））………………………………………………………………………………………...
（場所及び日付）（注５）………………………………………………………………………………………..
（輸出者の氏名又は名称（活字体によるもの））………………………………………………………………………………………..
Bulgarian version(Период: от …………… до …………(1))
EU/JP/Annex 3-D/en 1Износителят на продуктите, обхванати от този документ (износител № …(2)), декларира, чеосвен когато е отбелязано друго, тези продукти са с/със … преференциален произход(3).
(Използвани критерии за произход(4))…………………………………………………………….............................................
(Място и дата(5))...……………………………………………………………………..............................
(Наименование с печатни букви на износителя)...……………………………………………………………………..............................

Croatian version(Razdoblje: od …………… do …………(1))
Izvoznik proizvoda obuhvaćenih ovom ispravom (referentni broj izvoznika: ……...(2)) izjavljuje dasu, osim ako je drukčije izričito navedeno, ovi proizvodi ...……… preferencijalnog podrijetla(3).
(Primijenjeni kriteriji podrijetla(4))…………………………………………………………….............................................
(Mjesto i datum(5))...……………………………………………………………………..............................
(Ime izvoznika tiskanim slovima)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 2

Czech version(Období: od …………… do …………(1))
Vývozce výrobků uvedených v tomto dokumentu (referenční číslo vývozce ……...(2)) prohlašuje, žekromě zřetelně označených, mají tyto výrobky preferenční původ v ………(3).
(Použitá kritéria původu(4))…………………………………………………………….............................................
(Místo a datum(5))...……………………………………………………………………..............................
(Jméno vývozce tiskacím písmem)...……………………………………………………………………..............................

Danish version(Periode: fra …………… til …………(1))
Eksportøren af varer, der er omfattet af nærværende dokument, (eksportørreferencenr. ...............(2)),
erklærer, at varerne, medmindre andet tydeligt er angivet, har præferenceoprindelse i ........(3).
(Anvendte oprindelseskriterier(4))…………………………………………………………….............................................
(Sted og dato(5))...……………………………………………………………………..............................
(Eksportørens navn med blokbogstaver)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 3

Dutch version(Tijdvak: van …………… tot en met …………(1))

De exporteur van de producten waarop dit document van toepassing is (referentienr.
exporteur ……...(2)) verklaart dat, behoudens uitdrukkelijke andersluidende vermelding, dezeproducten van preferentiële oorsprong zijn uit ........(3).
(Gebruikte oorsprongscriteria(4))…………………………………………………………….............................................
(Plaats en datum(5))...……………………………………………………………………..............................
(Naam van de exporteur in blokletters)...……………………………………………………………………..............................

English version(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 ...……… preferential origin(3).
(Origin criteria used(4))…………………………………………………………….............................................
(Place and date(5))...……………………………………………………………………..............................
(Printed name of the exporter)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 4

Estonian version(Ajavahemik: alates …………… kuni …………(1))
Käesoleva dokumendiga hõlmatud toodete eksportija (eksportija viitenumber ……...(2)) kinnitab, etvälja arvatud selgelt osutatud juhtudel on need tooted ...……… sooduspäritoluga(3).
(Kasutatud päritolukriteeriumid(4))…………………………………………………………….............................................
(Koht ja kuupäev(5))...……………………………………………………………………..............................
(Eksportija nimi suurtähtedega)...……………………………………………………………………..............................

Finnish version(…………… ja ………… välinen aika(1))
Tässä asiakirjassa mainittujen tuotteiden viejä (viejän viitenumero ……(2)) ilmoittaa, että nämä
tuotteet ovat, ellei toisin ole selvästi merkitty, etuuskohteluun oikeutettuja …….. alkuperätuotteita(3).
(Käytetyt alkuperäkriteerit(4))…………………………………………………………….............................................
(Paikka ja päiväys(5))...……………………………………………………………………..............................
(Viejän nimi painokirjaimin)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 5

French version(Période: du …………… au …………(1))
L’exportateur des produits couverts par le présent document (nº de référence exportateur .........(2))
déclare que, sauf indication claire du contraire, ces produits ont l’origine préférentielle ………(3).
(Critères d’origine appliqués(4))…………………………………………………………….............................................
(Lieu et date(5))...……………………………………………………………………..............................
(Nom en caractères d’imprimerie de l’exportateur)...……………………………………………………………………..............................

German version(Zeitraum: von …………… bis …………(1))
Der Ausführer (Referenznummer des Ausführers ……...(2)) der Waren, auf die sich dieses
Handelspapier bezieht, erklärt, dass diese Waren, soweit nicht anders angegeben,
präferenzbegünstigte Ursprungswaren ...……….(3) sind.
(Verwendete Ursprungskriterien(4))…………………………………………………………….............................................
(Ort und Datum(5))...……………………………………………………………………..............................
(Name des Ausführers in Druckbuchstaben)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 6

Greek version(Περίοδος: από …………… έως …………(1))Ο εξαγωγέας των προϊόντων που καλύπτονται από το παρόν έγγραφο (αριθ. αναφοράς
εξαγωγέα ......(2)) δηλώνει ότι, εκτός αν ρητά δηλώνεται διαφορετικά, αυτά τα προϊόντα είναιπροτιμησιακής καταγωγής ...………(3).
(Χρησιμοποιούμενα κριτήρια καταγωγής(4))…………………………………………………………….............................................
(Τόπος και ημερομηνία(5))...……………………………………………………………………..............................
(Επωνυμία του εξαγωγέα ολογράφως)...……………………………………………………………………..............................

Hungarian version(Időszak: ……………-tól …………-ig(1))
A jelen okmányban szereplő áruk exportőre (az exportőr azonosító száma ....……(2)) kijelentem,hogy egyértelmű eltérő jelzés hiányában az áruk preferenciális ………..(3) származásúak.
(Alkalmazott származási feltételek(4))…………………………………………………………….............................................
(Hely és dátum(5))...……………………………………………………………………..............................
(Az exportőr nyomtatott neve)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 7

Italian version(Periodo: dal …………… al …………(1))

L'esportatore delle merci contemplate nel presente documento(numero di riferimentodell'esportatore ……...(2)) dichiara che, salvo indicazione contraria, le merci sono di origine
preferenziale ....................(3).
(Criteri di origine usati(4))…………………………………………………………….............................................
(Luogo e data(5))...……………………………………………………………………..............................
(Nome stampato dell'esportatore)...……………………………………………………………………..............................

Latvian version(Laikposms: no …………… līdz …………(1))
To produktu eksportētājs, kuri ietverti šajā dokumentā (eksportētāja atsauces numurs ……...(2)),
deklarē, ka, izņemot tur, kur ir citādi skaidri noteikts, šiem produktiem ir ...……… preferenciālaizcelsme(3).
(Izmantotie izcelsmes kritēriji(4))…………………………………………………………….............................................
(Vieta un datums(5))...……………………………………………………………………..............................
(Eksportētāja vārds vai nosaukums drukātiem burtiem)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 8

Lithuanian version(Laikotarpis nuo …………… iki …………(1))Šiame dokumente išvardytų prekių eksportuotojas (Eksportuotojo registracijos Nr. ……...(2))
deklaruoja, kad, jeigu aiškiai kitaip nenurodyta, tai yra ...……… preferencinės kilmės prekės(3).
(Taikyti kilmės kriterijai(4))…………………………………………………………….............................................
(Vieta ir data(5))...……………………………………………………………………..............................
(Atspausdintas eksportuotojo vardas ir pavardė (pavadinimas)...……………………………………………………………………..............................

Maltese version(Perjodu: minn …………… sa …………(1))
L-esportatur tal-prodotti koperti b’dan id-dokument (Numru ta’ Referenza tal-Esportatur ……...(2))
jiddikjara li, ħlief fejn indikat b’mod ċar li mhux hekk, dawn il-prodotti huma ta’ oriġinipreferenzjali ...………(3).
(Kriterji tal-oriġini użati(4))…………………………………………………………….............................................
(Il-post u d-data(5))...……………………………………………………………………..............................
(L-isem stampat tal-esportatur)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 9

Polish version(Okres: od …………… do …………(1))
Eksporter produktów objętych niniejszym dokumentem (nr referencyjny eksportera ……...(2))
deklaruje, że z wyjątkiem gdzie jest to wyraźnie określone, produkty te mają preferencyjne
pochodzenie ...………(3).
(Zastosowane kryteria pochodzenia(4))…………………………………………………………….............................................
(Miejsce i data(5))...……………………………………………………………………..............................
(Wydrukowana nazwa / imię i nazwisko eksportera)...……………………………………………………………………..............................

Portuguese version(Período: de …………… a …………(1))

O abaixo assinado, exportador dos produtos abrangidos pelo presente documento [referência doexportador n.º ……...(2)], declara que, salvo indicação expressa em contrário, estes produtos sãode ...……… origem preferencial(3).
(Critérios de origem utilizados(4))...……………………………………………………………………..............................
(Local e data(5))...……………………………………………………………………..............................
(Nome impresso do exportador)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 10

Romanian version(Perioada: de la …………… până la …………(1))
Exportatorul produselor care fac obiectul prezentului document (numărul de referință alexportatorului ……...(2)) declară că, exceptând cazul în care în mod expres este indicat altfel, aceste
produse sunt de origine preferențială ...………(3).
(Criteriile de origine utilizate(4))…………………………………………………………….............................................
(Locul și data(5))...……………………………………………………………………..............................
(Numele exportatorului, în clar)...……………………………………………………………………..............................

Slovak version(Obdobie: od …………… do …………(1))
Vývozca výrobkov uvedených v tomto dokumente (referenčné číslo vývozcu ……...(2)) vyhlasuje,že pokiaľ nie je jasne uvedené inak, majú tieto výrobky preferenčný pôvod v ...………(3).
(Použité kritériá pôvodu(4))…………………………………………………………….............................................
(Miesto a dátum(5))...……………………………………………………………………..............................
(Meno vývozcu tlačenými písmenami)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 11

Slovenian version(Obdobje: od …………… do …………(1))
Izvoznik blaga, zajetega s tem dokumentom (referenčna št. izvoznika ……...(2)), izjavlja, da, razen
če ni drugače jasno navedeno, ima to blago preferencialno.......................................... poreklo(3).
(Uporabljeni kriteriji glede porekla(4))…………………………………………………………….............................................
(Kraj in datum(5))...……………………………………………………………………..............................
(Natisnjeno ime izvoznika)...……………………………………………………………………..............................

Spanish version(Período: del …………… al …………(1))

El exportador de los productos incluidos en el presente documento (número de referencia delexportador ……...(2)) declara que, excepto donde se indique claramente lo contrario, estos productos
son de origen preferencial ...………(3).
(Criterios de origen aplicados(4))…………………………………………………………….............................................
(Lugar y fecha(5))...……………………………………………………………………..............................
(Nombre impreso del exportador)...……………………………………………………………………..............................

EU/JP/Annex 3-D/en 12

Swedish version(Period: Från den …………… till den …………(1))
Exportören av de varor som omfattas av detta dokument (exportörens referensnummer ……...(2))
försäkrar att dessa varor, om inte annat tydligt markerats, ...……… har förmånsberättigande
ursprung(3).
(Ursprungskriterier som använts(4))…………………………………………………………….............................................
(Plats och datum(5))...............................................................................................................
(Exportörens namn, med tryckbokstäver)...............................................................................................................
(1)

If the statement on origin is completed for multiple shipments of identical originatingproducts within the meaning of subparagraph 5(b) of Article 3.17, indicate the period forwhich the statement on origin will apply. That period shall not exceed 12 months. All
importations of the product must occur within the period indicated. Where a period is notapplicable, the field can be left blank.

EU/JP/Annex 3-D/en 13

(2)Indicate the reference number through which the exporter is identified. For the European
Union exporter, this will be the number assigned in accordance with the laws and regulationsof the European Union. For the Japanese exporter, this will be the Japan Corporate Number.
Where the exporter has not been assigned a number, this field may be left blank.

(3)

Indicate the origin of the product; the European Union or Japan.

(4)

Indicate, depending on the case, one or more of the following codes;"A" for a product referred to in subparagraph 1(a) of Article 3.2;

"B" for a product referred to in subparagraph 1(b) of Article 3.2;

"C" for a product referred to in subparagraph 1(c) of Article 3.2, with the following
additional information on the type of product specific requirement actually applied tothe product;"1"

for a change in tariff classification rule;"2"

for a maximum value of non-originating materials or a minimum regional value
content rule;

EU/JP/Annex 3-D/en 14

"3"for a specific production process rule; or"4"

in case of application of the provisions of Section 3 of Appendix 3-B-1;"D" for accumulation referred to in Article 3.5; or"E" for tolerances referred to in Article 3.6.
(5)

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

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