Name and address of the person concerned
Indication of applicable article of DA
Name and address of the customs office which granted repayment/remission
Reference to the decision granting repayment/remission
Name and address of monitoring customs office
Description of the goods, number and type
CN code of the goods
Quantity or net mass of the goods
Customs value of the goods
Date and relevant box to be ticked
Place and date and signature
Stamp
Observations