Manufactures Affidavit

Date:

Entry Number: _______________________

Date of Entry: ________________________

Port/District: _________________________

Description of Merchandise: ____________________________________________

I, (Name)____________________________________, signing as (Title)_____________________

for (Name of Company) ___________________________________________________________,

do hereby certify as to the following:

That we are the manufactures of the above mentioned merchandise having manufactured these articles in our plant in (State) _________________. These articles are being returned without having been advanced in value or improved in  condition by any process of manufacture or other means. No drawback, bounty or allowance has been paid or admitted thereon, or any part thereof.

Sincerely,