Secure Form

DECLARATION FOR FREE ENTRY OF RETURNED AMERICAN PRODUCTS

Port
 
Date
 ...
Entry No.
 
Entry Date
 ...
Name of Manufacturer
 
City & State of Manufacture
 
Reason for Return

U.S. DRAWBACK PREVIOUSLY

PREVIOUSLY IMPORTED UNDER HTSUS 864.05?
MARKS, NUMBERS, AND DESCRIPTION OF ARTICLES RETURNED VALUE*
* If the value of the article is $10,000 or more and the articles are not clearly marked with the name and address of U.S. manufacturer, please attach copies of any documentation or other evidence that you have that will support or substantiate your claim for duty free status as American Goods Returned.
I declare that the information given above is true and correct to the best of my knowledge and belief; that the articles described above are the growth, production, and manufacture of the United States and are returned without having been advanced in value or improved in condition by any process of manufacture or other means; that no drawback bounty, or allowance have been paid or admitted thereon, or on any part thereof; and that if any notice(s) of exportation of articles with benefit of drawback  filed upon exportation of the merchandise from the United States, such notice(s)  been abandoned.  
Name of Declarant
 
Title of Declarant
 
Name of Corporation or Partnership   Signature

SIGNATURE OF AUTHORIZING CBP OFFICER


NOTE: If the owner or ultimate consignee is a corporation, this form must be signed by the president, vice president, secretary, or treasurer of the corporation, or by any employee or agent of the corporation who holds a power of attorney and a certificate by the corporation that such employee or agent has or will have knowledge of the pertinent facts.

PAPERWORK REDUCTION ACT NOTICE: This information is needed to ensure that importers/exporters are complying with customs laws, to allow us to compute and collect the right amount of money, to enforce other agency requirements, and to collect accurate statistical information on imports. Your response is mandatory. The estimated average burden associated with this collection is 6 minutes per respondent or recordkeeper depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to Bureau of Customs and Border Protection, Information Services Branch, Washington DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0011), Washington DC 20503.

US Express Freight Systems
3240 Hubbard Rd, Landover, MD 20785 USA
(800) 328-8000

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