I, __________, declare that to the best of my knowledge and belief the __________ were assembled in whole or in part from fabricated components listed and described below, which are products of the United States:
Marks of identification, numbers | Description of component | Quantity | Unit value at time and place of export from United States1 | Port and date of export from United States | Name and address of manufacturer |
1 In accordance with U.S. Note 4 to Subchapter II of Chapter 98, Harmonized Tariff Schedule of the United States (19 U.S.C. 1202 ).
Description of the operations performed abroad on the exported components (in sufficient detail to enable Customs officers to determine whether the operations performed are within the preview of subheading 9802.00.80, Harmonized Tariff Schedule of the United States (19 U.S.C. 1202 ) (attach supplemental sheet if more space is required)):
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Date Signature
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Address Capacity
I declare that to the best of my knowledge and belief the (above), (attached) declaration, and any other information submitted herewith, or otherwise supplied or referred to, is correct in every respect and there has been compliance with all pertinent legal notes to the Harmonized Tariff Schedule of the United States (19 U.S.C. 1202 ).
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Date Signature
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Address Capacity
19 C.F.R. §10.24