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FROM: TO: TAX IDENTIFICATION NUMBER: 3. PRODUCER'S NAME AND ADDRESS 4. IMPORTER'S NAME AND ADDRESS: TAX IDENTIFICATION NUMBER: TAX IDENTIFICATION NUMBER: 5. DESCRIPTION OF GOOD(S): 6. H.S. TARIFF CLASSIFICATION NUMBER 7. PREFERENCE CRITERION 8. PRODUCER 9. NET COST 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 MAT.

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