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

View Form 3495 Instructions

DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection

OMB APPROVAL NO. 1651-0004
EXPIRATION DATE 08-31-2017
ESTIMATED BURDEN 8 MIN.

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
3. Name of Exporting Carrier

4. Date of Departure

5. Country of Origin

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
13. Place of CBP Examination

Date

14. Date

15. CBP PORT DIRECTOR
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

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
1651-0004. Obligation to respond is required to Obtain Benefits. The estimated average time to
complete this application is 8 minutes. If you have any comments regarding the burden estimate
you can write to U.S. Customs and Border Protection, Office of Trade, Regulations and Rulings,
90 K Street, NE., Washington DC 20229.

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

(Previous Editions are Obsolete)
CBP Form 3495 (8/17)

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