Mine-of-Origin and Chain-of-Custody Declaration

Records where a lot was mined and every party that held it. Required for 3TG, gold, cobalt and rough diamonds.

1. Lot

Supplier

Lot / batch reference

Mineral and product form

Quantity (net dry weight)

Grade (from assay report no.)

Traceability tag or certificate numbers

2. Mine of origin

Mine or site name

Licence number and holder

Province / district / territory

GPS coordinates

Industrial, or artisanal and small-scale?

Site validation status and date (if applicable)

3. Chain of custody

Every party that owned or physically held the material between the mine and this sale, in order.

Party	Role (miner, trader, processor, transporter, exporter)	Location	Dates held	Document reference

4. Export

Export licence / permit number

Export certificate (e.g. ICGLR, KP) number

Port of export

Taxes and royalties paid (receipt references)

Declaration

We declare that this material was lawfully mined, traded and exported; that to the best of our knowledge after due enquiry its extraction, transport and trade did not involve or benefit any of the abuses listed in Annex II of the OECD Due Diligence Guidance; and that all taxes, fees and royalties due have been paid.

For the supplier

Signature

Name

Position

Date

Company stamp