Form 17 Andean Trade Preferences Act (APTA) Declaration

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1651-0091
Expires 05/31/2013

U.S. Customs and Border Protection

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)
(Country)

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

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:
Description
of Articles

Invoices
Date
Number

Date

Address

Quantity

Processing operations
performed on articles
Direct costs
Description of processing
of processing
operations and
operations
country of processing

Signature

Material produced in a beneficiary country
or in the U.S.
Description of material,
Cost or
production process, and
value of
country of production
material

Title

CBP Form 17 (02/11)

ANDEAN TRADE PREFERENCE ACT (ATPA) DECLARATION
CONTINUATION

Invoices
Date
Number

Initials

Description
of Articles

Quantity

Processing operations
performed on articles
Direct costs
Description of processing
of processing
operations and
operations
country of processing

Page

of

Material produced in a beneficiary country
or in the U.S.
Description of material,
Cost or
production process, and
value of
country of production
material

CBP Form 17 (02/11)