DEPARTMENT OF THE TREASURY
UNITED STATES CUSTOMS SERVICE
NORTH AMERICAN FREE TRADE AGREEMENT
CERTIFICATE OF ORIGIN
Please print or type
1. EXPORTER NAME AND ADDRESS
19 CFR 181.11, 181.22
2. BLANKET PERIOD (D /M /Y ) D M Y
TO TAX IDENTIFICATION NUMBER: 3. PRODUCER NAME AND ADDRESS 4. IMPORTER NAME AND ADDRESS
TAX IDENTIFICATION NUMBER: 5. DESCRIPTION OF GOOD(S)
TAXIDENTIFICATION NUMBER: 7. 6. PREFERENCE HS TARIFF CLASSIFICATION CRITERION NUMBER 8. PRODUCER 9. NET COST 10. COUNTRY OF ORIGIN
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 W ITH THIS DOCUMENT; • I AGREETO 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 NORTHAMERICAN 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 • THIS CERTIFICATE CONSISTS OF
11a. AUTHORIZED SIGNATURE
PAGES, INCLUDING ALL ATTACHMENTS.
11c. NAME (P t o T p ) rin r y e
11e. DATE (D /M /Y ) D M Y 11f. TELEPHONENUMBER (V ic ) o e (F c im ) a s ile
Customs Form 434 (121793)
PAPERWORK REDUCTION ACT NOTICE: This information is needed to carry out the terms of the North American Free Trade Agreement (NAFTA). NAFTA requires that, upon request, an importer must provide Customs with proof of the exporter's written certification of the origin of the goods. The certification is essential to substantiatecompliance with the rules of origin under the Agreement. You are required to give us this information to obtain a benefit.
Statement Required by 5 CFR 1320.21: The estimated average burden associated with this collection of information is 15 minutes per respondent or recordkeeper depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions forreducing this burden should be directed to U.S. Customs Service, Paperwork Management Branch, Washington DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1515-0204), Washington DC 20503.
NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN INSTRUCTIONS For purposes of obtaining preferential tariff treatment, this document must be completed legibly and infull by the exporter and be in the possession of the importer at the time the declaration is made. This document may also be completed voluntarily by the producer for use by the exporter. Please print or type:
FIELD 1: State the full legal name, address (including country) and legal tax identification number of the exporter. Legal taxation number is: in Canada, employer number or importer/exporternumber assigned by Revenue Canada; in Mexico, federal taxpayer's registry number (RFC); and in the United States, employer's identification number or Social Security Number. Complete field if the Certificate covers multiple shipments of identical goods as described in Field # 5 that are imported into a NAFTA country for a specified period of up to one year (the blanket period). "FROM" is the dateupon which the Certificate becomes applicable to the good covered by the blanket Certificate (it may be prior to the date of signing this Certificate). "TO" is the date upon which the blanket period expires. The importation of a good for which preferential treatment is claimed based on this Certificate must occur between these dates. State the full legal name, address (including country) and...
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