INSERT COMPANY LETTERHEAD – MUST INCLUDE FULL ADDRESS AND CONTACT DETAILS

AUSTRALIA-UNITED STATES FREE TRADE AGREEMENT DECLARATION STATEMENT OF UNITED STATES ORIGIN

I (enter name) of (Name of Company) hereby state that the goods supplied to (Australian Importers Name) in Invoice No. (s) (enter invoice #) and described below are of US originating goods as defined in selected Section of the Customs Act of 1901.

Model(s)/Products Number(s) Description of Goods

…………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………………………………………………………………….

The above mentioned goods are:

PART A (Please tick one of the Following)

( ) Wholly obtained or wholly produced from US originating materials of the USA or USA and Australia as defined in AUSFTA; (eg. Fished, Mined, Grown, Bred, etc.,) [WO – Section 153YB]

OR

( ) Entirely produced in the USA, or in the USA and Australia exclusively from originating components/materials, as defined in the AUSFTA; [POM – Section 153YC]

OR

( ) Produced from USA originating and non-originating material as defined in AUSFTA, and satisfy the requirements of the product specific rule of origin relating to those goods, as detailed in Annex 4A or 5A of AUSFTA and according to:

(If you have declared that this statement relates to the goods covered by this declaration, please provide further details set out as below by the 4 sub-criteria) [PS – Section 153YE or YH]

OR

( ) Otherwise qualify as originating goods as prescribed , under the rules of origin in AUSFTA and stipulated in the Customs (Australia-US Free Trade Agreement) Regulations 2004.

(If you have declared that this statement relates to the goods covered by this declaration, please provide further details on the criteria for claiming preference) [PS – Section 153YE or YH]

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

PART B

In addition, we declare that the goods have:

( ) Been transported directly to Australia from the USA as per the AUSFTA requirements,

OR

( ) Been transported through another country or place but have not undergone any process of production in that country or place, other than unloading and reloading or any other operation to preserve them in good condition necessary for the goods to be transported to Australia.

WE agree to maintain and present on request, documentation necessary to support this statement. We further agree to inform, in writing, all persons to whom this statement was given of any changes that could affect the accuracy or validity of this statement.

Full Name (printed): ………………………………………………………………. Position: ………………………………………………………………..

Signed: ……………………………………………………………………………………. Dated: …………………………………………………………………..

AUSFTA Declaration Parts-Model Number Specific May 09 (2)