CBP Form 28 Request for Information

OMB Control NO: 1561-0023
Expiration Date: 02-28-2022

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
REQUEST FOR INFORMATION
19 CFR 151.11
Date of Request

Date of Entry and Importation

Manufacturer/Seller/Shipper

Carrier

Invoice Description of Merchandise
Country of Origin/Exportation

Entry No.
Invoice No.

HTSUS Item No.

CBP Broker Company Name

TO: Name: (Last, First, Middle Initial)

Broker Filer Code/Number
FROM:
Street 1:

Street 1:
Street 2:

Street 2:
City:

State:

Zip Code:

City:

State:

Zip Code:
Date Information
Furnished

Port

Production of Documents and/or Information Required by Law: If you have
provided the information requested on this form to U.S. Customs and Border
Protection at other ports, please indicate the port of entry to which it was
supplied, and furnish a copy of your reply to this office, if possible.

GENERAL INFORMATION AND INSTRUCTIONS
Please Answer Indicated Question(s)
A.

B.

Please Furnish Indicated Item(s)

Are you related (see reverse) in any way to the seller of this
merchandise? If you are related, please describe the
relationship, and explain how this relationship affects the price
paid or payable for the merchandise.

A.

Copy of contract (or purchase order and seller's confirmation
thereof) covering this transaction, and any revisions thereto.

B.

Descriptive or illustrative literature or information explaining what
the merchandise is, where and how it is used, and exactly how it
operates.

C.

Breakdown of components, materials, or ingredients by weight and
the actual cost of the components at the time of assembly into the
finished article.

D.

Submit samples:
Article number and description

Identify and give details of any additional costs/expenses
incurred in this transaction, such as:

from container

(1) packing

(4) assists

mark(s)and number

(2) commissions

(5) royalties and/or license fees

Samples consumed in analysis, and other samples whose return
is not specifically requested, will not normally be returned.

(3) proceeds that accrue to the seller
E.

See item below.

CBP Officer Message

Reply Message (If more space is needed, see continuation on page 2.)
CERTIFICATION

It is required that an appropriate corporate/company official execute this certificate and/or endorse all correspondence in response to
the information requested. (NOTE: NOT REQUIRED IF FOREIGN FIRM COMPLETES THIS FORM.)

I hereby certify that the information furnished herewith or upon this form in response to this inquiry is true and correct, and that any samples provided were
taken from the shipment covered by this entry.
Name (Last, First, Middle Initial) of Signer (Owner, Importer, or Corporate/Company Official)

Title/Position

Telephone No.

Date

Signature

CBP Official
Fax No.
CBP Form 0028 (8/21)

Team Designation

Telephone No.

Email
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