DEPARTMENT OF THE TREASURY
UNITED STATES CUSTOMS SERVICE
NORTH AMERICAN FREE TRADE AGREEMENT
CERTIFICATE OF ORIGIN
OMB No. 1515-0204
Please print or type 19 CFR 181.11,181.22
1. EXPORTER NAME AND ADDRESS 2. BLANKET PERIOD (DD/MM/YY)
FROM
TO
TAX IDENTIFICATION NUMBER:
3. PRODUCER NAME AND ADDRESS 4. IMPORTER NAME AND ADDRESS
TAX IDENTIFICATION NUMBER: TAX IDENTIFICATION NUMBER:
5.
DESCRIPTION OF GOODS
6.
HS TARIFF
CLASSIFICATION
NUMBER
7.
PREFERENCE
CRITERION
10.
COUNTRY
OF ORIGIN
8.
PRODUCER
9.
NET COST
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 AGREE TO 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 NORTH AMERICAN 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 PAGES, INCLUDING ALL ATTACHMENTS.
11a. AUTHORIZED SIGNATURE: 11b. COMPANY:
11c. NAME (Print or Type): 11d. TITLE:
11e. DATE (DD/ MM/YY ): (Voice) (Facsimile)
11f.
TELEPHONE
NUMBER
Customs Form 434 (121793)
