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Certificate of Origin: Please Print or Type

This document is a Certificate of Origin form for goods being exported from All Safe, Inc. in the U.S. to qualify for preferential tariff treatment under the North American Free Trade Agreement (NAFTA). The form contains fields to identify the exporter, producer, importer, product information including classification numbers, origin criteria, net cost, and country of origin. By signing the form, the authorized official certifies that the information is accurate and assumes responsibility, and that the goods meet NAFTA's rules of origin.

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SonNguyen
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48 views2 pages

Certificate of Origin: Please Print or Type

This document is a Certificate of Origin form for goods being exported from All Safe, Inc. in the U.S. to qualify for preferential tariff treatment under the North American Free Trade Agreement (NAFTA). The form contains fields to identify the exporter, producer, importer, product information including classification numbers, origin criteria, net cost, and country of origin. By signing the form, the authorized official certifies that the information is accurate and assumes responsibility, and that the goods meet NAFTA's rules of origin.

Uploaded by

SonNguyen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DEPARTMENT OF THE TREASURY

UNITED STATES CUSTOMS SERVICE

NORTH AMERICAN FREE TRADE AGREEMENT


CERTIFICATE OF ORIGIN
Please print or type 19 CFR 181.11, 181.22
1. EXPORTER NAME AND ADDRESS 2. BLANKET PERIOD (DD/MM/YY)

deAll Safe, Inc.


26643 Fallbrook Ave FROM
Wyoming, MN 55092 01/01/2017
TO

12/31/2017
TAX IDENTIFICATION NUMBER:
3. PRODUCER NAME AND ADDRESS 4. IMPORTER NAME AND ADDRESS

All Safe, Inc.


26643 Fallbrook Ave
Wyoming, MN 55092

TAX IDENTIFICATION NUMBER:


TAX IDENTIFICATION NUMBER: 04-3802290
5. 6. 7. 8. 9. 10.
DESCRIPTION OF GOOD(S) HS TARIFF PREFERENCE PRODUCER NET COST COUNTRY
CLASSIFICATION CRITERION OF
NUMBER ORIGIN

I C ER T IF Y T H AT :

•T H E IN F O R MAT IO N O N T H IS D O C U MEN T IS T R U E AN D AC C U R AT E AN D I A SSU ME T H E R ESPO N S IB IL IT Y F O R PR O VIN G S U C H R EP-


R ESEN T AT IO N S. I U N D ER ST AN D T H AT I A M L I ABLE F O R AN Y F ALSE ST AT EMEN T S O R MAT ER I AL O MIS S IO N S MAD E O N O R IN C O N -
N EC T IO N W IT H T H IS D O C U MEN T ;

•I AG R EE T O MA IN T AIN , AN D PR ES EN T U PO N R EQ U EST , DO CU MEN T AT IO N N EC ESS AR Y T O SU PPO R T T H IS C ER T IF IC AT E, AN D T O


IN F O R M, IN W R IT IN G , ALL PER SO N S T O W HO M T H E C ER T IF I C AT E W AS G IVEN O F AN Y C H AN G E S T H AT CO U LD AF F ECT T H E AC C U -
R AC Y O R VAL ID IT Y O F T H IS C ER T IF IC AT E;

•T H E GO O D S O R IG IN AT ED IN T H E T ER R IT OR Y O F O N E O R MO R E O F T H E PAR T IES, AN D C O MPL Y W IT H T H E OR IG IN R EQ U IR E MEN T S


SPEC IF IED F O R T H O SE G OO D S IN T H E N O RT H AMER IC AN F R EE T R AD E AG R EE MEN T , AN D U N LES S SP EC IF IC ALL Y EX E MP T E D IN
AR T IC LE 411 O R AN N E X 401, T H ER E H AS BEEN N O F U R T H ER PR O D U C T IO N O R AN Y OT H ER O PER AT IO N O UT SID E T H E T ER R IT O R IES
O F T H E PAR T IES; AN D

•T H IS C ER T IF IC AT E C O N SI ST S O F PAG ES, IN C LU D IN G ALL AT T AC H MEN T S.


11a. AUTHORIZED SIGNATURE 11b. COMPANY

All Safe, Inc.


11 11c. NAME (Print orType) 11d. TITLE
.
Jen Soper Shipping Manager
11e. DATE (DD/MM/YY) 11f. (Voice) (Facsimile)
TELEPHONE >
05/01/2017 NUMBER
612-332-3473 Ext 111 651-408-7163
Customs Form 434 (121793)

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