DECLARATION

 

I, declare that the articles listed below and covered by the entry to which this declaration relates are wholly the growth, product, or manufacture of a single foreign territory or country or insular possession of the United States as identified below. I declare that the information set forth in this declaration is correct and true to the best of my information, knowledge and belief.

A. (Name of Country)

Marks of
Identification,
Numbers

Description of Articles
and Quantity

Country of
Origin
   

A

Date:

Name:

Signature: __________________________________

Title:
Company:
Address: