Cbp Form 434 - North American Free Trade Agreement Certificate Of Origin
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2OMB No. 1651-0098
DEPARTMENT OF HOMELAND SECURITY
Exp. 03-31-2017
U.S. Customs and Border Protection
NORTH AMERICAN FREE TRADE AGREEMENT
CERTIFICATE OF ORIGIN
19 CFR 181.11, 181.22
1. EXPORTER NAME, ADDRESS AND EMAIL
2. BLANKET PERIOD
FROM (mm/dd/yyyy)
TO (mm/dd/yyyy)
TAX IDENTIFICATION NUMBER:
3. PRODUCER NAME, ADDRESS AND EMAIL
4. IMPORTER NAME, ADDRESS AND EMAIL
TAX IDENTIFICATION NUMBER:
TAX IDENTIFICATION NUMBER:
6.
7.
10.
5.
8.
9.
HS TARIFF
PREFERENCE
COUNTRY
DESCRIPTION OF GOOD(S)
CLASSIFICATION
PRODUCER
NET COST
CRITERION
OF ORIGIN
NUMBER
I CERTIFY THAT:
•
THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH
REPRESENTATIONS. I UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMISSIONS MADE ON OR IN
CONNECTION WITH THIS DOCUMENT;
•
I AGREE TO MAINTAIN AND PRESENT UPON REQUEST, DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE, AND TO INFORM, IN
WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY OF
THIS CERTIFICATE;
•
THE GOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OF THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS
SPECIFIED FOR THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE
411 OR ANNEX 401, THERE HAS BEEN NO FURTHER PRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE
PARTIES; AND
•
PAGES, INCLUDING ALL ATTACHMENTS.
THIS CERTIFICATE CONSISTS OF
11a. AUTHORIZED SIGNATURE
11b. COMPANY
11c. NAME
11d. TITLE
11.
11e. DATE (mm/dd/yyyy)
11f. TELEPHONE NUMBERS
11g. EMAIL
(Voice)
(Facsimile)
CBP Form 434 (11/16)
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