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DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

OMB No. 1651-0098 Exp. 03-31-2012 See back of form for Paperwork Reduction Act Notice.

Please print or type
1. EXPORTER NAME AND ADDRESS

NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN
19 CFR 181.11, 181.22
2. BLANKET PERIOD FROM TO 4. IMPORTER NAME AND ADDRESS

TAX IDENTIFICATION NUMBER: 3. PRODUCERNAME AND ADDRESS

AVAILABLE UPON CUSTOMS REQUEST

TAX IDENTIFICATION NUMBER: 5. DESCRIPTION OF GOOD(S)

TAX IDENTIFICATION NUMBER: 6. 8. 7. HS TARIFF PREFERENCE PRODUCER CLASSIFICATION CRITERION NUMBER

9. NET COST

10. COUNTRY OF ORIGIN

• THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH

I CERTIFY THAT:

• I AGREE TO MAINTAIN ANDPRESENT UPON REQUEST, DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE, AND TO INFORM, IN • THE GOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OF THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS SPECIFIED • THIS CERTIFICATE CONSISTS OF
FOR THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE 411 OR ANNEX 401, THERE HAS BEEN NO FURTHERPRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE PARTIES; AND WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY OF THIS CERTIFICATE;

REPRESENTATIONS. I UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMISSIONS MADE ON OR IN CONNECTION WITH THIS DOCUMENT;

1

PAGES, INCLUDING ALL ATTACHMENTS. 11b.COMPANY 11d. TITLE 11f. TELEPHONE NUMBER (Voice) (Facsimile)

11a. AUTHORIZED SIGNATURE 11c. NAME (Print or Type) 11. 11e. DATE (MM/DD/YYYY)

CBP Form 434 (04/97)

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 CBP with proof of the exporters writtencertification of the origin of the goods. The certification is essential to substantiate compliance with the rules of origin under the Agreement. You are required to give us this information to obtain a benefit.

The estimated average burden associated with this collection of information is 15 minutes per respondent or recordkeeper depending on individual circumstances. Comments concerning theaccuracy of this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs and Border Protection, Information Services Branch, Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0098), Washington DC 20503.

NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN INSTRUCTIONS For purposes of obtaining preferentialtariff treatment, this document must be completed legibly and in full 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: FIELD 2: State the full legal name, address (including country) and legal tax identification number of theexporter. Legal taxation number is: in Canada, employer number or importer/exporter number 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 aspecified period of up to one year (the blanket period). "FROM" is the date upon which 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...
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