116897754159

1. Goods consigned from ( exporter's business name, address, Reference No. 0000748/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : FOLEGANDROS 146N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : LOS ANGELES

DATE OF : NOVEMBER 25, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
1 MADE IN INDONESIA 9 CT W 9503 864 PCE 489B/EXP.LBJ/11
TOTAL : 837 PO NO.: L-4061200 960810 93.03 KGM 21
CARTONS DISNEY ITEM : 400932913360 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q321U027 2021
STAT321 PEN ARIEL
864 PCS / 9 CTNS

2 9 CT W 9503 864 PCE 489B/EXP.LBJ/11

PO NO.: L-4061200 960810 93.6 KGM 21
DISNEY ITEM : 400932913377 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q321U028 2021
STAT321 PEN BELLE
864 PCS / 9 CTNS

3 13 CT W 9608 1,248 PCE 489B/EXP.LBJ/11

PO NO.: L-4061200 960810 90.23 KGM 21
DISNEY ITEM : 400932913384 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q321U030 2021
STAT321 PEN GROOT
1248 PCS / 13 CTNS

4 9 CT W 9608 864 PCE 489B/EXP.LBJ/11

PO NO.: L-4061200 960810 113.18 KGM 21
DISNEY ITEM : 400932913391 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q321U031 2021
STAT321 PEN DVADER
864 PCS / 9 CTNS

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 24, 2022 GRESIK, JANUARY 24, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 1 / 5
 116897754159

1. Goods consigned from ( exporter's business name, address, Reference No. 0000748/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : FOLEGANDROS 146N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : LOS ANGELES

DATE OF : NOVEMBER 25, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
5 9 CT W 9608 864 PCE 489B/EXP.LBJ/11
PO NO.: L-4061200 960810 154.39 KGM 21
DISNEY ITEM : 400941265344 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q122U004 2021
STAT122 FIGPEN BEAST
864 PCS / 9 CTNS

6 9 CT W 9608 864 PCE 489B/EXP.LBJ/11

PO NO.: L-4061200 960810 118.63 KGM 21
DISNEY ITEM : 400941265351 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q122U005 2021
STAT122 FIGPEN BUZZ
864 PCS / 9 CTNS

7 9 CT W 9608 864 PCE 489B/EXP.LBJ/11

PO NO.: L-4061200 960810 86.52 KGM 21
DISNEY ITEM : 400941265368 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q122U006 2021
STAT122 FIGPEN SALLY
864 PCS / 9 CTNS

8 9 CT W 9608 864 PCE 489B/EXP.LBJ/11

PO NO.: L-4061200 960810 235.79 KGM 21
DISNEY ITEM : 400941265375 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q122U007 2021
STAT122 FIGPEN CHEWY
864 PCS / 9 CTNS

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 24, 2022 GRESIK, JANUARY 24, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 2 / 5
 116897754159

1. Goods consigned from ( exporter's business name, address, Reference No. 0000748/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : FOLEGANDROS 146N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : LOS ANGELES

DATE OF : NOVEMBER 25, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
9 70 CT W 9503 840 PCE 489B/EXP.LBJ/11
PO NO.: L-4788733 950300 357.5 KGM 21
DISNEY ITEM : 400929814281 NOVEMBER 19,
SUPPLIER STYLE NO.: 020Q221U012 2021
FIG SET PLY IN PARK S21
840 PCS / 70 CTNS

10 12 CT W 9608 1,152 PCE 489B/EXP.LBJ/11

PO NO.: L-4998497 960810 97.2 KGM 21
DISNEY ITEM : 400944270758 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q222U010 2021
PR222 TIANA FIG PEN
1152 PCS / 12 CTNS

11 16 CT W 9608 1,536 PCE 489B/EXP.LBJ/11

PO NO.: L-4988434 960810 180.8 KGM 21
DISNEY ITEM : 400943967307 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q222U011 2021
PR222 RPNZL FIG PEN
1536 PCS / 16 CTNS

12 35 CT W 9608 2,520 PCE 489B/EXP.LBJ/11

PO NO.: L-4233331 960810 198.1 KGM 21
DISNEY ITEM : 400926363386 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q121U032 2021
MNIAM121 PEN LUP
2520 PCS / 35 CTNS

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 24, 2022 GRESIK, JANUARY 24, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 3 / 5
 116897754159

1. Goods consigned from ( exporter's business name, address, Reference No. 0000748/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : FOLEGANDROS 146N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : LOS ANGELES

DATE OF : NOVEMBER 25, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
13 52 CT W 9608 4,992 PCE 489B/EXP.LBJ/11
PO NO.: L-4094405 960810 307.51 KGM 21
DISNEY ITEM : 400916563383 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q220U089 2021
TS20 FORKY FIG PEN
4992 PCS / 52 CTNS

14 49 CT W 9608 4,704 PCE 489B/EXP.LBJ/11

PO NO.: L-4233323 960810 340.11 KGM 21
DISNEY ITEM : 400932913384 NOVEMBER 19,
SUPPLIER STYLE NO.: 050Q321U030 2021
STAT321 PEN GROOT
4704 PCS / 49 CTNS

15 30 CT W 9503 720 PCE 489B/EXP.LBJ/11

PO NO.: L-4964452 950300 93 KGM 21
DISNEY ITEM : 400942915941 NOVEMBER 19,
SUPPLIER STYLE NO.: 020Q122U029 2021
TS PARACHUTE FIGS H22
720 PCS / 30 CTNS

16 375 CT W 9503 1,500 PCE 489B/EXP.LBJ/11

PO NO.: L-4055365 950300 93 KGM 21
DISNEY ITEM : 400916215251 NOVEMBER 19,
SUPPLIER STYLE NO.: 020S320U020 2021
ACC20 AVN CAMPUS FIG SET
1500 PCS / 375 CTNS

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 24, 2022 GRESIK, JANUARY 24, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 4 / 5
 116897754159

1. Goods consigned from ( exporter's business name, address, Reference No. 0000748/GRS/2022
country)
PT LANGGENG BUANA JAYA
VETERAN MADYA NO.8
INDONESIA GENERALIZED SYSTEM OF PREFERENCES
CERTIFICATE OF ORIGIN
2. Goods consigned to (consignee's name, address, country) (Combined declaration and certificate)

DISNEY THEME PARK MERCHANDISE FORM A

DISTRIBUTION CENTER BUILDING 100
Issued in INDONESIA
1020 W. BALL ROAD ANAHEIM, CA 92803
(country)
UNITED STATES OF AMERICA

See notes overleaf

3. Means of transport and route (as far as known) 4. For official use

SHIPPED BY : FOLEGANDROS 146N ISSUED RETROSPECTIVELY

FROM : SURABAYA (PTT)

TO : LOS ANGELES

DATE OF : NOVEMBER 25, 2021

SHIPMENT

5. Item 6. Marks and 7. Number and kind of packages; description of goods 8. Origin 9. Gross weight 10. Number
num- numbers of criterion or other and date of
ber packages (see notes quantity invoices
overleaf)
17 122 CT W 9503 7,808 PCE 489B/EXP.LBJ/11
PO NO.: L-4334861 950300 612.15 KGM 21
DISNEY ITEM : 400930063579 NOVEMBER 19,
SUPPLIER STYLE NO.: 020Q221U007 2021
THE CHILD PULLBACK
7808 PCS / 122 CTNS

11. Certification 12. Declaration by the exporter

It is hereby certified, on the basis of control carried out, that The undersigned hereby declares that the above details and
the declaration by the exporter is correct. statements are correct; that all the goods were
INDONESIA
produced in ..............................................................................
ISSUING OFFICE IN KABUPATEN GRESIK (country)
and that they comply with the origin requirements specified
for those goods in the generalized system of preferences for
goods exported to

UNITED STATES OF AMERICA

..................................................................................................
AGUS BUDIONO (importing country)
GRESIK, JANUARY 24, 2022 GRESIK, JANUARY 24, 2022
..................................................................................................... ..................................................................................................
Place and date, signature and stamp of certifying authority Place and date, signature of authorized signatory

Page 5 / 5