Affidavit Of Usa And Non-Usa Origin Form
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1Manhattan Chamber of Commerce
th
1120 Avenue of Americas 4
Floor
New York, NY 10036
AFFIDAVIT OF USA AND NON-USA ORIGIN
Now comes the affiant who deposes and says:
In regard to the products being shipped to ____________________________ by
____________________________, the affiant certifies that the component parts of the products
purchased originated in the following countries:
____________________________________________________(approx.
% of total product)
____________________________________________________(approx.
% of total product)
____________________________________________________(approx.
% of total product)
and that the component parts of the products were assembled in
______________________________________.
In consideration of the Manhattan Chamber of Commerce of the United States of
America certifying that all products purchased were comprised of component parts of both United
States origin and non-United States Origin and that the component parts were assembled in
_____________________, the affiant covenants and agrees to indemnify and save harmless the
Manhattan Chamber of Commerce of the United States of America, its’ agents, servants, employees,
principals, officers, directors, parent corporations, holding companies, successors and predecessors,
from and against any and all claims and demands made by or on behalf of the above-mentioned
buyer by reason of asserted rights, claims or demands for contribution (statutory or common law),
indemnification or indemnity (express or implied), subrogation, assignment and any and all claims
and demands, actions, and causes of action, of whatever nature, kind, or character, including any and
all costs, expenses and attorney fees incurred by reason of any such claim, demands, or causes of
action arising from and by reason of the above-mentioned certification by the Manhattan Chamber of
Commerce of the United States of America.
______________________________
(Signature)
By: _________________________________
(Print Name)
Title: ________________________________
STATE OF ______________________________
COUNTY OF_____________________________, TO WIT:
Taken, subscribed and sworn to before me, a notary public in and for the county and state
aforesaid, by ______________________________ of __________________________, this
_____day of __________ 20___.
____________________________________
Notary Public
My commission expires: __________________
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