[To be completed on Manufacturer’s/Supplier’s Letterhead]

Australia-United States Free Trade Agreement Declaration

Statement of United States Origin

I ______of ______(Name of Company) hereby state that the goods supplied to ______(Australian Importer’s Name) on Invoice No. (s) …………. are of US originating goods as defined in the selected Section of the Customs Act of 1901.

The goods are:

PART A (Please tick one of the following)

( ) Wholly obtained or wholly produced from US originating materials of the USA or USA and Australia, as defined in AUSFTA;(e.g. Fished, Mined, Grown, Bred, etc.,) [WO - Section 153YB]

OR

( ) Entirely produced in the USA, or in the USA and Australia exclusively from originating components/materials, as defined in the AUSFTA; [POM - Section 153YC]

OR

( ) Produced from USA originating and non-originating materials, as defined in AUSFTA, and satisfy the requirements of the product specific rule of origin relating to those goods, as detailed in Annex 4A or 5A of AUSFTA and according to:

(If you have declared that this statement relates to the goods covered by this declaration, please provide further details as set out below by the 4 sub-criteria) [PS - Section 153YE or YH]

[ ] The De Minimis Rule – The goods have 10% of the Customs Value or less of non-originating materials, as per the AUSFTA Regulations.
OR
[ ] Change in Tariff Classification Rule – The goods meet the Change of Classification Rule, and/or other Rules, as per the AUSFTA Regulations.
AND/OR
[ ] Regional Value Content Rule – The goods meet the Regional Value Content Rule, stipulated at ___%
AND/OR
[ ] The goods meet any other requirements for Specific Goods (Chapter 28-40)

OR

( ) Otherwise qualify as originating goods as prescribed, under the rules of origin in AUSFTA, and stipulated in the Customs (Australia-US Free Trade Agreement) Regulations 2004.

(If you have declared that this statement relates to the goods covered by this declaration, please provide further details on the criteria for claiming preference.) [PS - Section 153YE or YH]

______

PART B

In addition, we declare that the goods have:

( ) Been transported directly to Australia from the USA as per AUSFTA requirements,

OR

( ) Been transported through another country or place but have not undergone any process of production in that country or place, other than unloading, reloading or any other operation to preserve them in good condition necessary for the goods to be transported to Australia.

We agree to maintain and present on request, documentation necessary to support this statement. We 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.

Full Name: (please print) ………….………………………..……… Position: ……………..………………………………..

Signed: …………………………………………………………..……… Dated: …………………………………......

AUSFTA Declaration Invoice Specific May 09