Proposed New Form with redline

Department of Homeland Security
U.S. Customs and Border Protection
Continued Dumping and Subsidy Offset Act of 2000 Form

OMB No. 1651-0086

Claimant's Information
1. Claimant's Name:
(As it appears on USITC List or Association Membership List, if applicable)
(If person's name list Last Name, First Name)
2. Mailing Address:
3. Address 2:
4. City:
5. State:
6. ZIP/Postal Code:
Check here if Mailing Address is a PO Box.
(Street Address is required when Mailing Address is a PO Box)
7. Street Address:
8. Address 2:
9. City:
10. State:
11. ZIP/Postal Code:
12. Business Type (select one):
Sole Proprietorship
Partnership
Corporation
13. Number Type (select one and enter number below):
Social Security Number
Employee Identification Number
Federal Tax Identification Number
Enter Number Here
Contact Information

(Primary Contact For All Certification Related Inquiries)

14. Contact Person:

15. Contact Email:

16. Contact Phone:

17. Contact Fax:

(If Different From Claimant's Mailing Address)
18. Address:
19. Address 2:
20. City:
21. State:
22. ZIP/Postal Code:
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CBP Form 7401 (04/09)

OMB No. 1651-0086
Federal Register Notice Information
23. Date of Federal Register Notice:
24. Are you claiming a CDSOA distribution as a successor company?
(See 19 C.F.R. 159.61(b)(i))

Yes
No

If YES, please provide the name of the company and the date of the succession:
Name

Date _________________

25. Are you an association, coalition, or cooperative that appears on the USITC
list and files on behalf of your members?
(See 19 C.F.R 159.61(b)(ii))

Yes
No

If YES, please provide Power of Attorney within 10 days of filing certification. Please mail Power of
Attorney to the following address:
Assistant Commissioner
Office of Administration
U.S. Customs and Border Protection
Revenue Division
Attn: Melissa Kurth
6650 Telecom Drive
Indianapolis, IN 46278
26. Are you filing as a member of an association, coalition, or cooperative
that appears on the USITC list?

Yes
No

If YES, please provide name of organization and the date you became a member:
Name

Start Date ___________________

27. Start Date of Qualifying Expenditures _______________________ NEW
28. End Date of Qualifying Expenditures _______________________ NEW
Previously Certified Qualifying Expenditures for All Filing Years
29. Manufacturing Facilities

____________________

30. Equipment

____________________

31. Research and Development

____________________

32. Personnel Training

____________________

33. Acquisition of Technology

____________________

34. Health Care Benefits for Employees Paid For by the Employer

____________________

35. Pension Benefits for Employees Paid For by the Employer

____________________

36. Environmental Equipment, Training or Technology

____________________

37. Acquisition of Raw Materials and Other Inputs

____________________

38. Working Capital or Other Funds Needed to Maintain Production

____________________

39. Total Amount of Qualifying Expenditures Previously Certified

____________________

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CBP Form 7401 (04/09)

OMB No. 1651-0086

Commerce Case Information
40. Total Amount of Qualifying Expenditures Previously Certified (from question #39 pg 2)
41. List Case Information For All The Cases With The Same Qualifying Expenditures On The Lines Provided Below
*Formula (Total Amt of Qualifying Expenditures Previously Certified - Prior Year Distributions = Net Amt)
Commerce Case
Number

Commerce Case Name
(Product/Country)

Page 3

Total Amount of Prior
Distributions for this
case

Net Amount of Qualifying
Expenditures

CBP Form 7401 (04/09)

OMB No. 1651-0086
Statement of Eligibility
42. ____________________________________________________ (Claimant's Name as it appears on USITC List or Association
Membership List) desire to receive a distribution and is eligible to receive a distribution as an affected domestic producer. I
affirm that the net amount certified for distribution does not encompass any qualifying expenditures for which distributions
previously have been made.
43. ____________________________________________________ (Claimant's Name as it appears on USITC List or Association
Membership List) remains in operation and continues to produce the product covered by the particular order or finding under
which the distribution is sought.
44. ____________________________________________________ (Claimant's Name as it appears on USITC List or Association
Membership List)has not been acquired by a company that opposed the investigation or acquired by a business related to a
company that opposed the investigation.
Certification
The information contained in this certification is true and accurate to the best of the knowledge and belief,
under penalty of law, of the claimant and the claimant has records to support the qualifying expenditures
being claimed.
45. Print Name of Person(s) Legally Authorized to Bind Producer

46. Date

47. Signature of Person(s) Legally Authorized to Bind Producer
48. Title of Person(s) Legally Authorized to Bind Producer
49. By submitting this certification, the certifier,_____________ , states that they are legally authorized to bind the producer and that
information contained in the certification is true and accurate to the best of the certifier's knowledge and belief under penalty of
law and the domestic producer has records to support the qualifying expenditures being claimed.

Privacy and Paperwork Reduction Act Statement
This statement is provided pursuant to the Privacy Act of 1974 (P.L. 93-579) for individuals seeking distributions under the
Continued Dumping and Subsidy Offset Act of 2000 (19 U.S.C. § 1675c, as amended). The requested information is collected
under the authority of 19 U.S.C. 1675c. The information collected on this form will be used by CBP to determine a claimant’s
eligibility for a distribution under the Continued Dumping and Subsidy Offset Act of 2000. Furnishing the information on this
form is voluntary, however, failure to provide all requested information may result in denial of your certification. The name of
the claimant, the total dollar amount claimed by that party on the certification, as well as the total dollar amount that CBP
actually disburses to that claimant as an offset, will be available for disclosure to the public, as specified in 19 C.F.R. § 159.63.
Public Law 104-134 (April 26, 1996) requires that any person doing business with the Federal government furnish a social
security number or tax identification number.
We estimate this form will take an average of 1 hour to complete, including the time for reviewing instructions, getting the
needed data, and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form,
including suggestions for reducing completion time, to CBP Office of Administration Revenue Division. The OMB number,
1651-0086, is currently valid. CBP may not collect this information, and you are not required to respond, unless this number is
displayed.
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CBP Form 7401 (04/09)