1

Exporter (Name and full address)

2

Consignee (Name and full address)

3

country and place of cultivation

4

country of destination in EU

5

Packing 5 kg or less (number of packings)

6

Description of goods

7

Packing between 5 and 20 kg (number of packings)

8

Net weight (kg)

Gross weight (kg)

9

DECLARATION BY EXPORTER The undersigned declares that the information shown above is correct.

Place and date: Signature:

10

CERTIFICATION BY THE ISSUING BODY

It is hereby certified that the rice described above is one of the varieties of fragrant rice listed in Annex III of Commission Implementing Regulation (EU) No 2020/761 and that the information shown in this certificate is correct.

Place and date: Signature: Stamp:

11

FOR COMPETENT AUTHORITIES IN THE EUROPEAN UNION”.