Form 17 Andean Trade Preferences Act (ATPA) Declaration

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection OMB No. 1651-0091

Expires 5/31/2011

ANDEAN TRADE PREFERENCE ACT (ATPA) DECLARATION

19 CFR Ch.1; §10.207 thru §10.211

I, _________________________________________________, hereby declare that the articles described below (a) were produced or manufactured in

(Name)

___________________________ by means of processing operations performed in that country as set forth below and were also subjected to processing operations in the other

(Country)

beneficiary country or countries (including the Commonwealth of Puerto Rico, the U.S. Virgin Islands, and any CBI beneficiary country) as set forth below and (b) incorporate

materials produced in the country named above or in any other beneficiary country or countries (including the Commonwealth of Puerto Rico, the U.S. Virgin Islands, and any CBI

beneficiary country) or in the customs territory of the United States (other than the Commonwealth of Puerto Rico) as set forth below:

Invoices		Description of Articles	Quantity	Processing operations performed on articles		Material produced in a beneficiary country or in the U.S.
Date	Number			Description of processing operations and country of processing	Direct costs of processing operations	Description of material, production process, and country of production	Cost or value of material
11/27/1022	AB1234567	WWWWWWWWWWWWWWW	99,999,999	WWWWWWWWWWWWWWW	99,999,999	WWWWWWWWWWWWW	99,999,999

Date __________ Address ____________________________________________ Signature _____________________________________ Title ___________________________

CBP Form XXXX (XX/11)

ANDEAN TRADE PREFERENCE ACT (ATPA) DECLARATION Page _____ of _____

CONTINUATION

Invoices		Description of Articles	Quantity	Processing operations performed on articles		Material produced in a beneficiary country or in the U.S.
Date	Number			Description of processing operations and country of processing	Direct costs of processing operations	Description of material, production process, and country of production	Cost or value of material

Intitials_________________

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0091. The estimated average time to complete this application is 10 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

CBP Form 17