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

DEPARTMENT OF HOMELAND SECURITY

OMB CONTROL NO. 1651-0004
EXPIRATION DATE: 11-30-2020

U.S. Customs and Border Protection

APPLICATION FOR EXPORTATION OF ARTICLES UNDER SPECIAL BOND
19 CFR 10.38

INSTRUCTIONS: The CBP Form 3495, Application for Exportation of Articles Under Special Bond, will only be required when merchandise has been
designated for examination. In those instances in which an export examination has been designated, the importer/broker is required to submit the form prior
to exportation to the Port Director or his/her designee. It shall be the responsibility of the importer of record to ensure the CBP Form 3495 is presented to the
port of exportation in sufficient time to perform the examination. The Port Director at the port of exportation will determine the time frame for presentation of
the form prior to exportation.

IMPORTER/AGENT EXPORT INFORMATION
FROM: (Importer or Agent)
Name (Last, First, MI):
Street Address Line 1:
Street Address Line 2:
City:

State:

Zip Code:

TO: CBP Port Director (Email and Address)
Port Email:
Street Address Line 1:
Street Address Line 2:
City:
State:

Zip Code:

Country of Origin

No. of Export Packages

NOTE: Please attach copy of export invoice describing articles to be exported.
Name of Exporting Carrier

Date of Departure

Port of Entry

Entry Number

Date Articles Available for CBP Examination

Signature of Importer or Agent

Date

Date Bonded Period Expires
Date

FOR CBP USE ONLY
NOTICE TO IMPORTER TO DELIVER ARTICLES TO BE EXAMINED AND IDENTIFIED FOR EXPORTATION
Place of CBP Examination
Date

CBP Port Director
By:

REPORT OF EXAMINATION
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.
No. of Export Packages

Date of Delivery for Exportation

Marks or Numbers on Export Packages

The articles covered by this application do not agree with the invoice in content or in number of packages as follows:

Officer Initials

Badge No.

Date

REPORT OF EXPORTATION
Home of Exporting Conveyance (Vessel, Railroad, Airline and Flight Number)
Date of Departure

Manifest No.

Officer Initials

Badge No.

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 upload one copy of this form to DIS for the port of origin upon exportation.)
CBP Form 3495 (3/20)

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