Annex V B TO PROTOCOL 1 SUPPLIER DECLARATION FOR PRODUCTS NOT HAVING PREFERENTIAL ORIGIN STATUS

I, the undersigned, declare that the goods listed on this invoice …⁽¹⁾ were produced in …⁽²⁾ and incorporate the following components or materials which do not have an ESA State, other ACP State, OCTs or Community origin for preferential trade:

…⁽³⁾ …⁽⁴⁾ …⁽⁵⁾ ……………… ……………… ………………⁽⁶⁾

I undertake to make available to the customs authorities, if required, evidence in support of this declaration.

…⁽⁷⁾ …⁽⁸⁾ …⁽⁹⁾