Ssssssssssss

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection IMPORTER ID INPUT RECORD
19 CFR 24.5

Approved OMB NO. 1651-0064 Exp. 09-30-2012 See back of form for Paperwork Reduction Act Notice. 1. TYPE OF ACTION (Mark all applicable) Notification of Change of address* importer's number Check here if you also want your address updated in the Fines, Change of name* Penalties, andForfeitures Office *NOTE--If a continuous bond is on file, a rider must accompany this change document. 2B. Social Security Number

2. IMPORTER NUMBER (Fill in one format):-2A. I.R.S. Number

2C.

Check here if requesting a CBP-assigned number and indicate reason(s). (Check all that apply.)

I have no IRS No.

I have no Social Security No.

I have not applied for either number.

I am nota U.S. resident

2D. CBP-Assigned Number

3. Importer Name 4. DIV/AKA/DBA DIV AKA 6. Type Corporation 5. DIV/AKA/DBA Name DBA

Partnership

Sole Proprietorship

Individual

U.S. Government

State/Local Governments

Foreign Governments

7. Importer Mailing Address (2 32-character lines maximum)

8. City 11. Country ISO Code (Non-U.S. Only)

9. State Code

10. ZIP

12.Importer Physical Location Address (2 32-character lines maximum, see instructions)

13. City 16. Country ISO Code (Non-U.S. Only)

14. State Code

15. ZIP

17a. Has importer ever been assigned a CBP Importer Number using the same 17b. Has importer ever been assigned a CBP Importer Number using a name name as in Block 3? different from that in Block 3? No Yes (List number(s) and/or name(s) inBlock 17c.) No Yes (List number(s) and/or name(s) in Block 17c.) 17c. If ''Yes'' to 17a and/or 17b, list number(s) and/or name(s)

I CERTIFY: That the information presented herein 18. Printed or Typed Name and Title is correct; that if my Social Security Number is used it is because I have no IRS Employer Number, that if my CBP assigned number is used it is because I have neither a SocialSecurity Number nor an IRS Employer Number, that if none 20. Signature of these numbers is used, it is because I have none, and my signature constitutes a request for assignment of a number by CBP. 22. Broker Use Only

19. Telephone No. Including Area Code

21. Date

X

Previous Editions are Obsolete

CBP Form 5106 (03/99)

PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct orsponsor 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 1651-0064. The estimated average time to complete this application is 6 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection,Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229. PRIVACY ACT STATEMENT: Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974, notice is hereby given that 19 CFR 24.5 authorizes the disclosure of Social Security numbers (SSN) on the CBP Form 5106. The principal purpose for disclosure of the Social Security number is to assure maintenance of records thathave a high degree of usefulness in regulatory investigations or proceedings. The information collected may be provided to those officers and employees of the CBP and any constituent unit of the Department of the Homeland Security who have a need for the records in the performance of their duties. The records may be referred to any department or agency of the federal government upon the requestof the head of such department or agency. The authority to collect the SSN is 31 CFR 103.25. The SSN will be used to identify the individuals conducting business with the CBP. BLOCK 1 - TYPE OF ACTION Notification of Importer's Number - Check this box if you are a first time importer, using an importer number for the first time, or if you have not engaged in CBP business within the last year....