Form CBP-FORM-3495 Application for Exportation of Articles Under Special Bo

Form Approved OMB No. 1651-0004

U.S. DEPARTMENT OF HOMELAND SECURITY

Bureau of Customs and Border Protection
APPLICATION FOR EXPORTATION OF ARTICLES UNDER SPECIAL BOND
19 CFR 10.38

TO CBP PORT DIRECTOR
1. TO: CBP Port Director (Address)

2. FROM: (Name and Address of Importer or Agent)

ATTACH COPY OF EXPORT INVOICE DESCRIBING ARTICLES TO BE EXPORTED
5. Country of Origin

3. Name of Exporting Carrier

4. Date of Departure

7. Port of Entry

8. Entry Number

10. Date Articles Available for CBP Examination

11. Signature of Importer or Agent

Date

6. No. of Export Packages

9. Date Bonded Period Expires

12. Date

(FOR CBP USE ONLY)

NOTICE TO IMPORTER TO DELIVER ARTICLES TO BE EXAMINED AND IDENTIFIED FOR EXPORTATION
Date

13. Place of CBP Examination

15. CBP PORT DIRECTOR

14. Date

BY:

REPORT OF EXAMINATION
16. The articles covered by this application have been examined and agree with the invoice in content and No. of export pkgs. and are approved for export.

17. No. of Export Packages

18. Date of Delivery for Exportation

19. Marks and Numbers on Export Packages

20. The articles covered by this application do not agree with the invoice in content or in number of packages as follows

21. SIGNATURE OF EXAMINING CBP OFFICER

22. DATE

REPORT OF EXPORTATION
23. Home of Exporting Conveyance (Vessel, Railroad, Airline and Flight Number)

24. Date of Departure

25. Manifest No.

26. SIGNATURE OF CBP OFFICER

(CBP officer must return one copy of this
form to port of origin upon exportation.)

PAPERWORK REDUCTION ACT NOTICE: The Paperwork Reduction Act says we must tell
you why we are collecting this information, and whether you have to give it to us. We need
this information to ensure that importers and exporters are complying with the Customs laws of
the United States and allow us to figure and collect the right amount of revenue. Your
response is mandatory. The estimated average burden associated with this collection of
information is 8 minutes per respondent or recordkeeper depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions
for reducing this burden should be directed to Bureau of Customs and Border Protection,
Information Services Group, Washington, DC 20229, and to the Office of Management and
Budget, Paperwork Reduction Project (1651-0004), Washington, DC 20503.
(Previous Editions are Obsolete)

CBP Form 3495 (08/99)