SINGLE COUNTRY DECLARATION

I,                            (name), declare that the articles listed below and covered by the invoice or 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 U.S. or were assembled in the single foreign territory or country, or insular possession of the U.S. of fabricated components which are in whole the product of the U.S. and/or the single foreign territory or country, or insular possession of the U.S. 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                                       (country*)

B                                       (country*)

C                                       (country*)

D                                       (country*)

Marks of identifi cation numbers	Description of article and quantity	Country* of origin	Date of exportation

Date

Name

Signature

Title

Company

Address

*Country when used in this declaration includes territories and U.S. insular possessions. If the entry or invoice to which the declaration relates covers merchandise from more than one country each country will be identified in the declaration by the alphabetical designation appearing next to the named country. In the case of an assembly operation of U.S. components, both the country of assembly and the U.S. shall be reported (e.g Haiti/U.S.) along with date of exportation from the country of assembly.