OMB 1651-0075 Exp.

10/31/2011

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection DELIVERY CERTIFICATE FOR PURPOSES OF DRAWBACK
19 CFR 191
PAPERWORK REDUCTION ACT NOTICE: This request is in accordance with the Paperwork Reduction Act.
We ask for the information in order to carry out U.S. Department of Homeland Security laws and regulations, to determine the eligibility for refund of taxes on domestic alcohol (if applicable), and to determine the proper amount of drawback. Your response is required to obtain or retain a benefit. The estimated average burden associated with this collection of information is 33 minutes per respondent depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs and Border Protection, Asset Management, Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0075) Washington, DC 20503.

Certificate of Delivery
1. CM&D No. 2. Port Code 3. DBK Ruling No.

Certificate of Manufacture and Delivery
TO TRANSFEREE:

4. Type Code

5. ID No. of Transferor

6.

FROM TRANSFEROR:

7.

RECEIVED DATE

Company Name and Complete Address

Company Name and Complete Address

IMPORTED DUTY PAID, DESIGNATED MERCHANDISE OR DRAWBACK PRODUCT
8. Use 9. Import Entry or CM&D Number 10. Port Code 11. Import Date (MM/DD/YYYY) 12. CD 13. (If using 1313(b)) A. B. Date(s) Date(s) Received Used 14. Date Delivered 15. HTSUS No. 16. Description of Merchandise (Include Part/Style/Serial Numbers) 17. Quantity & Unit of Measure 18. Entered Value Per Unit 19. 100% Duty

21. Contact Name and Address

PREPARER
Phone Number FAX Number Ext.

20.

Total

CBP Form 7552 (07/08)

22. Quantity & Description of Merchandise Used

23. Date(s) of Manufacture (MM/DD/YYYY)

24. Description of Articles Manufactured or Produced (Include Part/Style/Serial Numbers)

25. Quantity & Unit of Measure

26. Date Delivered

27. Duty Available on Manufacture Articles (Total of Duties in Block 20)

28. Drawback Available Per Unit of Measure on Manufactured Article

29. Factory Location

30. Exhibits to be attached for the following: Relative Petroleum Value

Domestic Tax Paid Alcohol

Piece Goods

Waste Calculation

Recycled

Harbor Maintenance Fee Merchandise Processing Fee Other Taxes/Fees

31. STATUS - Import Entries listed on this form are subject to (If CD, identify on this form; if CM&D, identify on coding sheet): Reconciliation 19 USC 1514, Protest 19 USC 1520 (c)(1) 19 USC 1520 (d)

DECLARATIONS
The merchandise transferred on this CD is the imported merchandise. The merchandise transferred on this CD is pursuant to 19 U.S.C. 1313(j)(2) and will not be designated for any other Drawback purposes. The article(s) described above were manufactured or produced and delivered as stated herein in accordance with the Drawback ruling on file with CBP and in compliance with applicable laws and regulations. This Certificate of Delivery is a subsequent transfer and the merchandise is the same as received.

The undersigned acknowledges statutory requirements that all records supporting the information on this document are to be retained by the issuing party for a period of three years from the date of payment of the related drawback entry. Assignment of Rights is transferred when this form is prepared as a CD or CM&D. I declare that according to the best of my knowledge and belief, all of the statements in this document are correct and I am fully aware of the sanctions provided in18 U.S.C.1001 and 18 U.S.C. 550 and 19 U.S.C. 1593a.

Member of Firm with Power of Attorney Printed Name and Title

Officer of Corporation

Broker with Power of Attorney

Signature and Date

CBP Form 7552 (07/08)

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