U.S. Customs and Border Protection
OMB No. 1651-0098 Exp. 03-31-2012
NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN
19 CFR 181.11, 181.22
1. EXPORTER NAME AND ADDRESS 2. BLANKET PERIOD FROM TO TAX IDENTIFICATION NUMBER: 3. PRODUCER NAME AND ADDRESS 4. IMPORTER NAME AND ADDRESS
TAX IDENTIFICATION NUMBER: 5. DESCRIPTION OF GOOD(S)
TAXIDENTIFICATION NUMBER: 6. 7. 8. 9. HS TARIFF PREFERENCE CLASSIFICATION PRODUCER NET COST CRITERION NUMBER 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 WITH THIS DOCUMENT;
• I AGREETO MAINTAIN AND PRESENT 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
WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY OF THIS CERTIFICATE; 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 PAGES, INCLUDING ALL ATTACHMENTS. 11b. COMPANY 11d. TITLE 11f. TELEPHONE NUMBERS (Voice) (Facsimile) 11a. AUTHORIZED SIGNATURE 11c. NAME 11e. DATE
• THIS CERTIFICATE CONSISTS OF
CBP Form 434(04/11)
PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0098. The estimated average time to complete this application is 15 minutes. If you have any comments regardingthe burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.
NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN INSTRUCTIONS For purposes of obtaining preferential tariff treatment, this document must be completed legibly and in full by the exporter and be in the possession of the importer at thetime 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 the exporter. Legal taxation number is: in Canada, employer number or importer/exporter number assigned by Revenue Canada; in Mexico, federaltaxpayer'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 date upon which Certificate becomes applicable to the good coveredby 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 legal tax identification number, as defined in Field #1, of theproducer. If more than one producer's good is included on the Certificate, attach a list of additional producers, including the legal name, address (including country) and legal tax identification number, cross-referenced to the good described in Field #5. If you wish this information to be confidential, it is acceptable to state "Available to CBP upon request". If the producer and the exporter are...