| 1a. U.S. PRINCIPAL PARTY IN INTEREST (USPPI)(Complete
name and address) |
2. DATE OF EXPORTATION |
3. TRANSPORTATION REFERENCE NO. |
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ZIP
CODE
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| 1b. USPPI’S
EIN (IRS) OR ID NO. |
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1c. PARTIES TO
TRANSACTION |
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| 4a.
ULTIMATE CONSIGNEE (Complete name and address) |
4b.
INTERMEDIATE CONSIGNEE (Complete name and address) |
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| 5a.
FORWARDING AGENT (Complete name and address) |
5b.
FORWARDING AGENT’S EIN (IRS) NO. |
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| 6.
POINT (STATE) OF ORIGIN OR FTZ NO. |
7.
COUNTRY OF ULTIMATE DESTINATION |
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| 8.
LOADING PIER (Vessel only) |
9.
METHOD OF TRANSPORTATION (Specify) |
14.
CARRIER IDENTIFICATION CODE |
15. SHIPMENT
REFERENCE NO. |
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| 10.
EXPORTING CARRIER |
11. PORT OF
EXPORT |
16. ENTRY
NUMBER |
17. HAZARDOUS
MATERIALS |
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| 12.
PORT OF UNLOADING (Vessel and air only) |
13
CONTAINERIZED (Vessel only) |
18. IN BOND
CODE |
19. ROUTED
EXPORT TRANSACTION |
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| 20.
SCHEDULE B DESCRIPTION OF COMMODITIES (Use columns 22–24) |
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VIN/PRODUCT NUMBER/
VEHICLE TITLE NUMBER (25) |
VALUE (U.S. dollars,
omit cents)
(Selling price or
cost if not
sold) (26) |
D/F
or M
(21) |
SCHEDULE B NUMBER (22) |
QUANTITY
–
SCHEDULE B UNIT(S)
(23) |
SHIPPING
WEIGHT
(Kilograms) (24) |
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| 27.
LICENSE NO./LICENSE EXCEPTION SYMBOL/AUTHORIZATION |
28. ECCN (When
required) |
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| 29.
Duly authorized officer or employee |
The USPPI
authorizes the forwarder named above to act as forwarding agent for
export control and customs purposes. |
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| 30.
I certify that all statements made and all information contained
herein are true and correct and that I have read and understand the
instructions for preparation of this document, set forth in the
"Correct Way to Fill Out the Shipper’s Export Declaration." I
understand that civil and criminal penalties, including forfeiture
and sale, may be imposed for making false or fraudulent statements
herein, failing to provide the requested information or for
violation of U.S. laws on exportation (13 U.S.C. Sec. 305; 22 U.S.C.
Sec. 401; 18 U.S.C. Sec. 1001; 50 U.S.C. App. 2410). |
| Signature |
Confidential – Shipper’s Export Declarations (or any
successor document) wherever located, shall be exempt from public
disclosure unless the Secretary determines that such exemption would
be contrary to the national interest (Title 13, Chapter 9, Section
301 (g)). |
|
| Title |
Export shipments are subject to inspection by U.S. Customs
Service and/or Office of Export Enforcement. |
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| Date |
31.
AUTHENTICATION (When required) |
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| Telephone No. (Include Area Code) |
E-mail
address |
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