Company Name

address
address
Phone / Fax

I, (Signors Name) of (Company Name) in the United States of America herby state that the goods
supplied to _______________________________________ are US originating goods as defined in
Section 153Y of the Customs Act 1901(and in paragraph 5.1 (a) of AUSFTA) as the are wholly
obtained or produces entirely in the US.
Description of Goods
Model/Product No. (if applicable)
Harmonized Tariff Code
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This statement applies to the goods above that are supplied on _________________________
Invoice #_______________________. I agree to maintain and present on request documentation
necessary to support this statement. I further agree to inform, in writing, all persons to whom the
statement was given of any changes that could affect the accuracy or validity of this statement.
Signed,

Name
Company
Title
Phone
Fax
Email: Website URL