DEPARTMENT OF I request that: (Mark only one code )

HOMELAND SECURITY
10 Bills, Refunds and 40 Bills and Notices 34 Checks and Notices
Notices of Liquidation
U.S. Customs and
Border Protection 20 Checks for Refunds or 23 Bills and Checks
Drawback only
SPECIAL 30 Bills Only 24 Notices of Liquidation only

be addressed to the undersigned in care of the agent whose Importer Number is shown below
ADDRESS whenever it appears as Reference Number on an Entry Summary (CBP 7501) for which I am (my
organization is) the Importer of Record.

NOTIFICATION Agent's Name _______________________________________ Agent's Number ________________

(Show hyphens)

My (organization's) Importer No.

(Show hyphens)
Note: A Report of Importer Principal
Number (CBP 5106) must be Member of Firm
______________________________________________ ________ _____________of the Corp.
on file for each Importer (Signature) (Date) (Title)
Number appearing on this
form. CBP Form 4811 (10/01)