U.s. Customs And Border Protection Certificate Of Origin

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OMB No. 1651-0016

Exp. 10-31-2011

DEPARTMENT OF HOMELAND SECURITY

1. PORT

U.S. Customs and Border Protection

2. DATE

3. CERTIFICATE NO.

CERTIFICATE OF ORIGIN

4. NAME OF PERSON COMPLETING CERTIFICATE

(ARTICLES SHIPPED FROM INSULAR POSSESSIONS,

EXCEPT PUERTO RICO, TO THE UNITED STATES 1)

5. NAME OF FIRM

19 CFR 7.3

6. SHIPPERS EXPORT DEC. NO.

7. DATE FILED

8. CARRIER (Vessel or Airline)

9. DESTINATION (Port of)

10. CONSIGNED TO

11. LOCATION OF CONSIGNEE (City and State)

FOREIGN MATERIALS

MATERIALS DESCRIBED IN GENERAL NOTE 3 (a)(iv)(B)(2)

12.

13.

14.

19.

17.

18.

MARKS AND

15.

16.

QUANTITY

DESCRIPTION OF ARTICLES

Date Incorporated into

Date Imported into

Description

NUMBERS

Description

Value

Imported Goods

Insuler Possession

20. INSULAR POSSESSION WHERE MERCHANDISE WAS PRODUCED OR MANUFACTURED 21. INSULAR POSSESSION OF WHICH MATERIALS ARE THE GROWTH, PRODUCT, OR MANUFACTURE

I declare that I am the person named above, acting in the capacity indicated; that the description and other particulars of the

22. ADDRESS OF SHIPPER

merchandise specified above are correct as set forth in this certificate; that the said merchandise was produced or manufactured in

the insular possession named above, and from the materials grown, produced, or manufactured in the insular possession also named

above, or of the United States, or of both; that if foreign materials were used therein, their description and value are shown above.

23. SIGNATURE OF SHIPPER

I hereby certify that I have investigated the foregoing

24. DATE

25. SIGNATURE OF CBP OFFICER

VERIFICATION OF

statements and am satisfied that they are correct to

CBP OFFICER