NEGARA BRUNEI DARUSSALAM 05

ROYAL CUSTOMS AND EXCISE DEPARTMENT

DUTIABLE IMPORTS DECLARATION FORM FORM C.17
Date Generated: 14/08/2025 11.59 PM - Page 1 of 2
PROCEDURE FOR OFFICIAL USE
1. Customs Procedure Code 94. Declaration Registration No. 95. Approved Date
Import 05 DEC-05612-202508-1491535 14/08/2025
2. Previous Procedure Code 96. Manifest Registration No. 97. Payment Date (if
applicable)
3. Transport Mode Code 4. Clearance Station Code
Land C Sungai Tujoh Control Post 612
Exporter/Consigner Importer/Consignee
5. Name: - 10. Name: NORAISHAH RAMLEE
6. Address 7. Registration No. 11. Address 12. Registration No.
- NO 21 SPG 74-59-108-37-102 KATOK -
8. Tel No. B MATA MATA 13. Tel No.
- -
9. Postal: - - 14. Postal:-
Transport Agent
20. Arrival Date : 15-08-2025 21. Containerised: No 15. Name: ATRIZ SERVICES (FA)
22. Vessel/Flight/Vehicle No. 23. Vessel Name: 16. Address 17. Registration No.
BBC7253 - NO.59, SPG 15-23, RPN KG PANDAN P30001681
24. BL/DO/AWB No. 25. HBL/HAWB No. KUALA BELAIT 18. Tel No.
- - 7456256
Brunei Darussalam 19. Postal: KA3131
26. Country of Shipment Code 27. Country of Destination Code
Malaysia MY458 Brunei Darussalam BN096
28. Port of Loading Code 29. Port of Discharge Code
Miri, Sarawak 6843 - -
30. Place of Release: - 31. Place of Receipt: - 39. Issue / Expiry
Supporting Documents 37. Permit/License No. 38. Issued By Date
32. Exchange Rate 33. Previous Declaration No. .
MYR 0.3029 -
34. Nature of Transaction
-
35. Invoice No.
KK2508/0475
36. Other No. 40. Letter No. 41. Letter Type 42. Letter Date
- - -
For Temporary Import
43. Type of Application 44. Granted Period (Months) 45. Est. Date of Export 46. Place of Exportation
- - -
47. Project Name 48. Project Date From 49. Project Date To
- -
For Transit
50. Mode of Transport: - 51. Means of Transport:
52. Office of Departure (1st Checkpoint) Code 53. Office of Final Destination (Last Checkpoint) Code
- - - -
54. Via 2nd Checkpoint Code 55. Via 3rd Checkpoint Code
- - - -
Security Deposit (For Transit and Temporary Import only)
56. Type of Deposit: - 57. Deposit Amount -
58. Bank Guarantee Amount (B$) 59. Bank Guarantee/Cheque No. 60. Bank Name Code
- - -
Goods
61. Total Gross Weight (Unit) 62. Total No. of Packages 63. Total Invoice Amount (B$) 64. Insurance (B$)
3 Kg 3 408.92 0.61
65. Freight Charges (B$) 66. Other Charges (B$) [Link]:FOB INV MYR1350.00
61.34 0.00
Goods (Continuation) Declaration Registration No. DEC-05612-202508-1491535 Page 2 of 2
68. No. of 69. Country
71. HS Code 72. UOM 73. Quantity
Packages of Origin
SN 70. Goods Description / Permit Info (PI)
74. Shipping [Link]
76. CIF Value (B$) 77. Duty Rate 78. Duty Payable (B$)
Marks No.

60 MY SELUAR 62092090 KGM 60.00

1
BBC7253 $209.27 $0.00

60 MY PAKAIAN 62092090 KGM 60.00

2
BBC7253 $104.64 $0.00

15 MY KASUT 64019290 UN2 15.00

3
BBC7253 $156.97 5% $7.85
No. of Goods: 3 Total Declared Value (B$): $470.88 Total Duty (B$): $8.00
Total CIF for dutiable goods (B$): $156.97 Total CIF for non-dutiable goods (B$): $313.91
Declaration
All the particulars declared by me/ us are true and correct.
79. Name: FARAHANA HJ SENIN 81. IC Colour:

80. IC No: 00316197 83. Date: 14/08/2025

82. Designation: -

Note: In completing this declaration, units and codes should be in accordance with the Brunei Trade Classification that is currently
enforced. Penalty for making an untrue or incorrect declaration: up to 12 months imprisonment and B$40,000 fine.

FOR OFFICIAL USE

Payment
84. Actual Total Duty Payable (B$): $8.00 89. Total Excise Duty Payable (B$): $0.00
85. Warehouse Rent (B$): $0.00 90. Total WTO Valuation Deposit $0.00
86. Parcel Clearance (B$): $0.00 91. Deducted Amount (B$): $0.00
87. Other Charges (B$): $0.00 92. Total Amount Payable (B$): $8.00
88. Total Deposit Payable (B$): $0.00 93. Receipt No:
98. Payment Status: Paid 101. Mode of Payment:
99. Payment Amount (B$): $8.00 102. Bank Name:
100. Payment Date: 14/08/2025
Verification by Proper Officer of Customs
Name: SYSTEM
Designation: - Date: 14/08/2025
Department: Royal Customs and Excise Department

Approval by Proper Officer of Customs

Name: SYSTEM
Designation: - Date: 14/08/2025
Department Royal Customs and Excise Department