Application for U.S. Custom “ Drawback “ Bond
Principal / President / Owner (Print Name):
Company Name: (Print only)
Complete Business Address, City, State and Zip (No PO. Box)
Phone # Fax #
What date you want your New bond to be Effective: ( Month / Date / Year )
IRS # / EIN # / Tax id: Number of Years in Business:
State Business Register (for LLC only): State of Incorporated:
Individual Sole Proprietorship Corporation LLC Partnership (Need Copy of Partnership Agreement
S.S.N (Only if you are applying under your personal name)
US Custom Assigned Bond # (if any): Surety Number (if any):
General Description of Merchandise you are importing:
Countries Importing From:
This Calendar Year Next Calendar Year
Estimated Imported Total Values:
Estimated Imported Total Duties Paid:
Drawback Value Requested This Year:
Drawback Value Approved Last Year:
Estimated Drawback Value This Year:
I/We/Applicant certified that the factual information contained in this application is true and accurate and was provided based upon the best available information at the time of this application. Further, I/We/Applicant agree that when this application is Signed and when Bond Application submitted and issued, I/We/Applicant will then be fully and contractually responsible for the full payment amount as confirmed and agreed herein. When applicant bond number/certificate is issue & if applicant/reseller refuses to pay within ten days, then bond provider has a right to cancel/terminate applicant bond anytime I/We/Applicant also understands that invoices and correspondence will be communicated thru the email address given herein. This bond application encompasses the terms, conditions and languages as specified in CBP-5291 (Power of Attorney Form) and satisfy the requirements of 19 CFR 149.5(c) and shall be retained by this bond provider for as long as applicants continues to use and operate the bond acquired thru this bond provider. I/We/Applicant acknowledges that when payment is made in-full there is/will be no pro-rate or refunds for any bond termination after activation. All Bond(S) are subject to approval by U.S. Custom and with your good credit
Signature: ______Date:
( Month / Date / Year )