Name and address of decision taking customs authority
Repayment/remission of duties — File reference of decision taking customs authority
Name and address of the customs office of the Member State where the goods are situated
Application of provisions on mutual assistance between the customs authorities
Location of goods (if applicable)
Name and full address of person from whom the information may be obtained or who can assist the customs office of the Member State where the goods are situated
List of documents attached
Purpose of the request
Decision taking customs authority – place and date – signature – stamp
Information obtained
Result of examination carried out
Place and date
Signature and official stamp