[별지 제5호의 4 서식] <신설 2026.4.29.>

Provenance of Object(s)

1. Name of Object(s):

2. Acquisition Date:

(Please specify the precise date, if possible.)

3. Acquisition Details

(Specify from where and whom the property was purchased, donated or otherwise acquired as much as possible.)

4. Existence of Certificate(s)

(Please enclose purchase receipt if any.)

I, the holder of the object(s), hereby warrant and undertake that the information stated above is true and correct and that the object(s) concerned is not associated with any illegal activities, including looting and theft.

Date
Full Name (of organization and representative)
Signature		Date of Birth
Address
Contact Information (Telephone Number)		(Mobile Phone Number)

* If the above statements are found to be false, or if the provenance, source or ownership of the object(s) is determined to be subject to significant dispute, the donation may be not accepted.