Form 5106 Importer Input Record

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
IMPORTER ID
INPUT RECORD
19 CFR 24.5

Approved OMB NO. 1651-0064
Exp. 09-30-2009
See back of form for Paperwork Reduction Act Notice.
1. TYPE OF ACTION (Mark all applicable)
Notification of
Change of address*
importer's number
Check here if you also want your
address updated in the Fines,
Change of name*
Penalties, and Forfeitures Office
*NOTE--If a continuous bond is on file, a rider must accompany this change document.

2. IMPORTER NUMBER (Fill in one format):-2A. I.R.S. Number

2C.

2B. Social Security Number

Check here if requesting a
CBP-assigned number and
indicate reason(s). (Check all that apply.)

I have no IRS No.

I have no
Social Security No.

I have not applied
for either number.

I am not a
U.S. resident

2D. CBP-Assigned Number

3. Importer Name
4. DIV/AKA/DBA
DIV
AKA

5. DIV/AKA/DBA Name
DBA

6. Type
Corporation

Partnership

Sole Proprietorship

Individual

U.S. Government

State/Local Governments

Foreign Governments

7. Importer Mailing Address (2 32-character lines maximum)

8. City

9. State Code

10. ZIP

11. Country ISO Code (Non-U.S. Only)

12. Importer Physical Location Address (2 32-character lines maximum, see instructions)

14. State Code

13. City

15. ZIP

16. Country ISO Code (Non-U.S. Only)

17a. Has importer ever been assigned a CBP Importer Number using the same 17b. Has importer ever been assigned a CBP Importer Number using a name
name as in Block 3?
different from that in Block 3?
No

Yes (List number(s) and/or name(s) in Block 17c.)

No

Yes (List number(s) and/or name(s) in Block 17c.)

17c. If ''Yes'' to 17a and/or 17b, list number(s) and/or name(s)

I CERTIFY: That the information presented herein 18. Printed or Typed Name and Title
is correct; that if my Social Security Number is
used it is because I have no IRS Employer
Number, that if my CBP assigned number is used it
is because I have neither a Social Security
Number nor an IRS Employer Number, that if none 20. Signature
of these numbers is used, it is because I have
none, and my signature constitutes a request for
assignment of a number by CBP.

19. Telephone No. Including Area Code

21. Date

X

22. Broker Use Only

Previous Editions are Obsolete

CBP Form 5106 (03/99)

Paperwork Reduction Act Notice: We need this information to establish the
Importer's name, address, and importer number. We will use this information
as basis for establishing bond coverage, release and entry of merchandise,
liquidation, issuance of bills and refunds, and processing of drawback and
FP&F actions. Your response is mandatory. The estimated average burden
associated with this collection of information is 6 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 U.S. Customs and Border Protection, Information
Services Branch, Washington, DC 20229 and to the Office of Management
and Budget, Paperwork Reduction Project (1651-0064) Washington, DC
20503.
PRIVACY ACT STATEMENT: Pursuant to the requirements of Public Law
93-579 (Privacy Act of 1974, notice is hereby given that 19 CFR 24.5
authorizes the disclosure of Social Security numbers (SSN) on the CBP Form
5106. The principal purpose for disclosure of the Social Security number is to
assure maintenance of records that have a high degree of usefulness in
regulatory investigations or proceedings. The information collected may be
provided to those officers and employees of the CBP and any constituent unit
of the Department of the Homeland Security who have a need for the records
in the performance of their duties. The records may be referred to any
department or agency of the federal government upon the request of the
head of such department or agency. The authority to collect the SSN is 31
CFR 103.25. The SSN will be used to identify the individuals conducting
business with the CBP.
BLOCK 1 - TYPE OF ACTION
Notification of Importer's Number - Check this box if you are a first time
importer, using an importer number for the first time, or if you
have not engaged in CBP business within the last year.
Change of Name - Check this box if this importer number is on file but there
is a change in the name on file.
Change of Address - Check this box if this importer number is on file but
there is a change in the address on file.
BLOCK 2 - IMPORTER
2A -IRS Number - Complete this block if you are assigned an Internal
Revenue Service employer identification number.
2B -Social Security Number - Complete this block if no Internal Revenue
Service employer identification number has been assigned. The Social
Security number should belong to the principal or owner of the
company or the individual who represents the importer of record.
2C

-Requesting a CBP Assigned Number - Complete this block if no
Internal Revenue Service employer identification number has been
assigned, or no Social Security number has been assigned. If this box
is checked, all corresponding boxes in 2C must also be marked.
PLEASE NOTE. A CBP Assigned Number is for CBP use only and
does not replace a Social Security number or Internal Revenue Service
employer identification number. In general, a CBP Assigned Number will
only be issued to foreign businesses or individuals, provided no IRS or
Social Security number exists for the applicant. If Block 2C is
completed, this form must be submitted in duplicate. CBP will issue an
Assigned Number and return a copy of the completed form with the
Assigned Number to the requester. This identification number will be
used for all future CBP transactions when an importer number is
required. If an Internal Revenue Service employer identification number
and/or a Social Security number are obtained after an importer number
has been assigned by CBP, the importer will continue to use the
assigned number unless otherwise instructed.

2D

-CBP Assigned Number - Complete this block if you are assigned a
CBP Assigned Number but there is an Action change (Block 1).
BLOCK 3 - IMPORTER NAME
If the name is an individual, input the last name first, first name, and middle
initial. Business names should be input first name first.
BLOCK 4 - DIV/AKA/DBA
Complete this block if an importer is a division of another company (DIV), is
also known under another name (AKA), or conducts business under another
name (DBA).
BLOCK 5 - DIV/AKA/DBA NAME
Complete this block only if Block 4 is used.
BLOCK 6 - TYPE OF COMPANY
Check applicable box. Please Note: Place an *X* after U.S. Gov't only for a
U.S. federal government department, agency, bureau or office. All federal
agencies are assigned I.R.S. numbers which should be used for any CBP
transactions by that agency.
BLOCK 7 - IMPORTER MAILING ADDRESS
This block must always be completed. It may or may not be the importer's
business address. Insert a post office box number, or a street number
representing the first line of the importer's mailing address (up to 32
characters). For a U.S. or Canadian mailing address, additional mailing
address information may be inserted (up to 32 characters). If a P.O. box
number is given for the mailing address, a second address (physical
location) must be provided in Block 12.
BLOCK 8 - CITY
Insert the city name of the importees mailing address.

BLOCK 9 - STATE
For a U.S. mailing address, insert a valid 2-position alphabetic U.S. state
postal code (see list below). For a Canadian mailing address, insert a 2character alphabetic code representing the province of the importer's
mailing address (see list below).
BLOCK 10 - ZIP CODE
For a U.S. mailing address, insert a 5 or 9 digit numeric ZIP code as
established by the U.S. Postal Service. For a Canadian mailing address, insert
a Canadian postal routing code. For a Mexican mailing address, leave blank.
For all other foreign mailing addresses, a postal routing code may be inserted.
BLOCK 11 -COUNTRY ISO CODE
For a U.S. mailing address, leave blank. For any foreign mailing address,
including Canada and Mexico, insert a 2 character alphabetic International
Standards Organization (ISO) code representing the country. Please Note:
Valid ISO codes may be found in Annex B of the Harmonized Tariff Schedule
of the United States; Customs Directive 099 5610-002, ''Standard Guidelines
for the Input of Names and Addresses into ACS Files"; or CBP Form 7501
Instructions".
BLOCK 12 - SECOND IMPORTER ADDRESS
If the importer's place of business is the same as the mailing address, leave
blank. If different from the mailing address, insert the importer's business
address in this space. A second address representing the importer's place of
business is to be provided if the mailing address is a post office box or
drawer.
BLOCK 13 - CITY
Insert the city name for the importer's business address.
BLOCK 14 - STATE
For a U.S. address, insert a 2 character alphabetic U.S. state postal code (see
list below). For a Canadian address, insert a 2 character alphabetic code
representing the province of the importer's business address (see list below).
BLOCK 15 - ZIP CODE
For a U.S. business address, insert a 5 or 9 digit numeric ZIP code as
established by the U.S. Postal Service. For a Canadian address, insert a
Canadian postal routing code. For a Mexican address, leave blank. For all
other foreign addresses, postal routing code may be inserted.
BLOCK 16 - COUNTRY ISO CODE
For a U.S. address, leave blank. For any foreign address, including Canada
and Mexico, insert a 2 character alphabetic ISO code representing the country.
BLOCK 17 - PREVIOUSLY ASSIGNED CUSTOMS IMPORTER NUMBER
Indicate whether or not importer has previously been assigned a CBP
Importer Number under the same name or a different name. If "Yes" to
either question, list name(s) and/or number(s) in Block 17c.

AL
AK
AZ
AR
AS
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO

OFFICIAL UNITED STATES POSTAL SERVICE
TWO-LETTER STATE AND POSSESSION ABBREVIATIONS
Alabama
MT
Montana
Alaska
NE
Nebraska
Arizona
NV
Nevada
Arkansas
NH
New Hamsphire
American Samoa
NJ
New Jersey
California
NM
New Mexico
Colorado
NY
New York
Connecticut
NC
North Carolina
Delaware
ND
North Dakota
Distric of Columbia
MP
Northern Mariana Islands
Federated States of Micronesia OH
Ohio
Florida
OK
Oklahoma
Georgia
OR
Oregon
Guam
PW Palau
PA
Pennsylvania
Hawaii
PR
Puerto Rico
Idaho
RI
Rhode Island
Illinios
SC
South Carolina
Indiana
SD
South Dakota
Iowa
TN
Tennessee
Kansas
TX
Texas
Kentucky
UT
Utah
Louisiana
VT
Vermont
Maine
VA
Virginia
Marshall Islands
Maryland
VI
Virgin Islands
Massachusetts
WA Washington
Michigan
WV West Virginia
Minnesota
WI
Wisconsin
Mississippi
WY Wyoming
Missouri

AB
BC
MB
NB
NL
NT

OFFICIAL TWO-LETTER CANADIAN PROVINCE CODES
NS Nova Scotia
Alberta
British Columbia
ON Ontario
Manitoba
PE Prince Edward Island
New Brunswick
QC Quebec
Newfoundland (Incl. Labrador)
SK Saskatchewan
Northwest Territories
YT Yukon Territory

CBP Form 5106 (03/99)(Back)