0 SADSAD 500

501 - CUSTOMS
- CUSTOMS DECLARATION
DECLARATION FORMSheet) OFFICE
(Continuation CODE 3. FORMS
1. DECLARATION REGISTRATION
A. OFFICENO
OFAND 7. DECLARANT
DESTINATION ORREFERENCE
DEPARTURE
1 1. 2.
IMPORTER OR EXPORTER DATE
EXPORTER/CONSIGNOR OFF. CODE MANIFEST NUMBER
2 TIN TIN102155
SAMCOL, SEDE DE LINGAMO KOM 1 2 2003KRI5652
72000009/GV122795/002/2020 4748757424
3
PARCELA
TOTAL SA 729, VIA 11130 NR A KOM633297 2020/02/25 [20-Mar-2020] 18:25:34 N
MZMPM
4
5 140 MATOLA MOZAMBIQUE BSIC
31. 3. FORMS32. ITEM
4. 33. COMMODITY
REGISTRATION CODE
NO. ASSESSMENT NO. AND DATE
6
PACKAGES
MARKS AND
AND 7
NUMBERS ACC: N/A 633297
DESCRIPTION
8
OF GOODS 1 of 1 1 27101230(1) 1051017
9 34. COC 35. GROSS MASS 36. PREF-
8. IMPORTER/CONSIGNEE
NUMBER & 5. ITEMS 6. TOT 7. DECLARANT REFERENCE NO
(KGS) RECEIPT NO. AND DATE
ERENCE
TYPE OF TIN 102155 PACK.
ANTHARYAMI LOGISTICS
PACKAGES
(PTY) LTD 2003KRI5652SG4748757424
1 1
[20-Mar-2020]
37. CPC N
18:25:34 38. NET MASS 39. QUOTA
BSIC 4960103580 (KGS)
CONTAINER 9. 10. 11. 12. VALUE DETAILS 13. 13A. INVOICE NO. AND DATE
NUMBERS 11 00 INV GV122795/2020/002
DESCRIPTION 40. 2020-02-24
SUMMARY DECLARATION/PREVIOUS
390135 DOC
DISTILLATE FUEL, AS DEFINED IN ADDITIONAL NOTE 1(G)
14. DECLARANT/AGENT 15. 16. 17. 17A. OWNER CODE 17B. REBATE USER CODE
TOP SEALS:
TOTAL SA C04757941 - C04757947 TIN 00102155 COE COO COD 41. SUPP. UNITS 42. CUSTOMS VALUE 43. V.M
38700.00 LI (FCY)
3 BIERMANN AVENUE MZ ZA 32136.00 KG
BOTTOM SEALS: C04757948 - C04757950
ROSEBANK 355846
20. DELIVERY TERMS
44. LICENCE NUMBER DEDUCTED VALUE DEDUCTED QUANTITY
ADDITIONAL JOHANNESBURG EX WAREHOUSE CODE 45. COUNTABLE
INFORMATION/ IPC IMP2019/10269 355846 38700.00 QUANTITY
18. IDENTIFICATION, DATE AND NATIONALITY OF 19. CON- 22. CURRENCY AND TOTAL VALUE 23. RATE OF EXCHANGE
TRANSPORT AT ARRIVAL
NUI NTAINER
PRODUCED
DOCUMENTS REMOVAL IN BOND (R.I.B.) NO, DATE AND OFFICE REBATE CODE 46. STATISTICAL VALUE
JXW934MP 2020/02/25 355846 355846
31. 21. IDENTIFICATION, DATE AND NATIONALITY OF 32. ITEM
28. Consignt 33. COMMODITY
/ Trans Particulars CODE
24. OTHER COSTS DETAILS
PACKAGES TRANSPORT AT FRONTIER UCR
MARKS AND Currency Amount
AND
NUMBERS
DESCRIPTION
OF GOODS
Trans Value 34. COC FREIGHT 35. GROSS MASS 36. PREF-
NUMBER & (KGS) ERENCE
25. OF 26.
TYPE 27. PLACE OF
PACKAGES
TMF TMI DISCHARGE
Receiving Bank INSURANCE38. NET MASS
37. CPC 39. QUOTA
3
CONTAINER (KGS)
NUMBERS
29. 30. LOCATION OF GOODS Credit Terms VAT Claim
OOE
DESCRIPTION OTHER
40. SUMMARY COST
DECLARATION/PREVIOUS DOC
Y
31. DIESEL 50PPM 32. 33. COMMODITY CODE
PACKAGES ITEM 41. SUPP. UNITS 42. CUSTOMS VALUE 43. V.M
MARKS AND (FCY)
AND
NUMBERS 27101230(1) 1051017
DESCRIPTION 1
OF GOODS LICENCE NUMBER
44. DEDUCTED VALUE DEDUCTED QUANTITY
ADDITIONAL EX WAREHOUSE
34. COC CODE 35. GROSS MASS 36. PREF.
45. COUNTABLE
INFORMATION/ NUMBER & QUANTITY
(KGS)
TYPE OF
PACKAGES 1 SG 34764.00
PRODUCED
DOCUMENTS REMOVAL IN BOND (R.I.B.) NO, DATE AND OFFICE REBATE CODE 37. CPC 46.38. NETT MASS
STATISTICAL VALUE 39. QUOTA
CONTAINER 11 00
NUMBERS
31. 32. ITEM 33. COMMODITY CODE
PACKAGES
40. PREVIOUS PROCEDURE MRN & LINE NO
MARKS AND
AND DESCRIPTION GV122795/2020/002
NUMBERS
DESCRIPTION DISTILLATE FUEL, AS DEFINED IN ADDITIONAL NOTE 1(G)
OF GOODS
34. COC41. 35. GROSS
SUPP. UNITS 42.MASS 36. PREF-
CUSTOMS VALUE 43. V.M
TOP& SEALS:
NUMBER C04735610-C04735617 (KGS) ERENCE
TYPE OF 41668.00 LI (FCY)
PACKAGES
BOTTOM: C04735618-C04735620. 34764.00 KG
37. CPC 38. NET MASS 39. QUOTA
355846
CONTAINER (KGS) N1
44. LICENCE NUMBER DEDUCTED VALUE DEDUCTED QUANTITY
NUMBERS EX WAREHOUSE CODE
ADDITIONAL 45. COUNTABLE
INFORMATION/ IPC IMP2019/10269 355846 38700.00 QUANTITIES
DESCRIPTION 40. SUMMARY DECLARATION/PREVIOUS DOC

PRODUCED
NUI N 41. SUPP. UNITS 42. CUSTOMS VALUE 43. V.M
(FCY)
DOCUMENTS PREVIOUS PROCEDURE MRN REBATE CODE 46. STATISTICAL VALUE
355846
44. LICENCE NUMBER DEDUCTED VALUE DEDUCTED QUANTITY
47.
ADDITIONAL TYPE DUTY/TAX BASE RATE AMOUNT MP 48. ACCOUNT CODE EX WAREHOUSE CODE
49. IDENTIFICATION OF
45. WAREHOUSE/TIME
COUNTABLE
INFORMATION/
CALCULATION QUANTITY LIMIT
OF DUTIES 1P1 70.82 8*****6843 D
AND TAXES
PRODUCED
DOCUMENTS REMOVAL IN BOND (R.I.B.) NO, DATE AND OFFICE12A 1477.18
REBATE CODE SUMMARY OF TOTAL DUTIES AND TAXES
46. STATISTICAL VALUE

15A 134289.00
47. TYPE DUTY/TAX BASE RATE AMOUNT MP TOTAL
TYPE DUTIES & TAXES
DUTY/TAX BASE RATE AMOUNT 252,463.00
MP
CALCULATION
OF DUTIES 15B 76626.00 AMOUNT OVERPAID
AND TAXES
AMOUNT UNDERPAID

OTHER

TOTAL PAYABLE 252,463.00

DECLARATION
TOTAL ON FIRST ITEM OF THIS PAGE TOTAL ON SECOND ITEM OF THIS PAGE
FOR OFFICIAL USE
TYPE
FEZI DUTY/TAX BASE
MASHABA RATE AMOUNTSA
TOTAL MP TYPE AMOUNT MP
I, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . the undersigned of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LRN No. :
1P1 70.8200102155KOM20200320633297
being the . ENTRY
. . . . . . . . . CLERK
. . . . . . . . . . . . . . . . . . . . . . . . . (agent) hereby declare that the particulars herein are
12A 1477.18
MRN No. :
true and correct and comply with the provisions of the Customs and Excise Act. 15A KOM202003215024118
134289.00
15B 76626.00
PRN No. :
25/02/2020
GRAND TOTAL FOR
Signature TOTAL ON THIRD ITEM OF THIS PAGE I.D number Date
ALL PAGES 212463.00
Prepared by AIR-SHIP Saturday, March 21, 2020 [05:53:14 AM] Form generated and produced by AIR-SHIP 1.0.0.9696