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APPLICATION FOR AUTHORITY TO RELEASE IMPORTED GOODS

(EXCISE VALUE-ADDED TAX)

IMPORTER OR OWNER: BUTUAN HJR INTERNATIONAL CORPORATION__________________TIN: 001-687-893-000


ADDRESS: KM TAGUIBO BUTUAN CITY, AGUSAN DEL NORTE PHILIPPINES__________________________________
BROKER: JOMAR SULAPAS LOBITANA_________________________________________TIN: 215-065-061-000___
VESSEL: ST GREEN V-004A B/L No EGLV235801195441 ARRIVAL DATE: JANUARY 13, 2019___________________
PLACE OF DELIVERY: (unloading point) MCT SUBPORT, TAGOLOAN MISAMIS ORIENTAL_______________________
(Specify complete address)

1. Description of Commodities (Attach packing list and bill of lading for ready reference)

B/L No. & Date NAME OF FLIGHT/


QUANTITY DESCRIPTION OF ARTICLE of issue VALUE AIRLINE/VESSEL VOYAGE No.

1825 BAGS PRAWN FEED EGLV235801195441 $ 23,658.24 ST GREEN V-004A

2. Detailed description of how the commodity (ies) is/are to be used (ex; machinery, raw materials, stocks in trade
supplies, personal use, etc.)Raw materials for manufacture of feeds ingredient for swine and poultry and not for specialty
feeds for race horses, aquarium fish, fighting cocks and zoo animals as generally considered as pets.

3. Legal basis for exemption from payment of VAT/excise tax(es) (State specific sections(s) of the particular law)

Section 4.109-1 (B)(1)(b) of RR # 16-2005, dated September 1,2005

I/We hereby declare under oath that the imported articles indicated above are those appearing in Invoice No
BHJR46/575/18 of SHENG LONG BIO-TECH INTERNATIONAL CO LTD Bill of Lading No EGLV235801195441 of EVERGREEN SHIPPING
(Name and Address of Foreign Firm) (Shipping/Airline Company)
and I/we hereby assume the full responsibility to any legal consequence that may arise from any misrepresentation on
my/our part if the imported article(s), upon inspection, prove to be different or are not the same as manifested, or if any
of the documents submitted in support of this application described the article(s) in a manner that will conceal their true
nature for the purpose of avoiding payment of the appropriate taxes.

Cagayan de Oro City, Philippines, January 11, 2019

JOMAR SULAPAS LOBITANA


Customs Broker _____
(Importer or his duly authorized representative)

Subscribed and sworn to before me this 11th day of January 2019, in CITY OF BUTUAN affiant exhibited to me
his/her Community Tax Certificate No. 411162475 issued at Butuan City on January 4, 2019.

Affix
Documentary Stamp
Here

Doc. No. ___________


Page No. ___________
Book No. ___________
Series of ___________