OMB 1651-0075 Exp.

10/31/2011
DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection Certificate of Delivery

DELIVERY CERTIFICATE FOR PURPOSES OF DRAWBACK 1. CM&D No. 2. Port 3. DBK Ruling No.
19 CFR 191 Certificate Code

PAPERWORK REDUCTION ACT NOTICE: This request is in accordance with the Paperwork Reduction Act. We ask for the information in
of
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 Manufacture
4. Type 5. ID No. of Transferor
applicable), and to determine the proper amount of drawback. Your response is required to obtain or retain a benefit. The estimated average burden and
associated with this collection of information is 33 minutes per respondent depending on individual circumstances. Comments concerning the accuracy of Code
this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs and Border Protection, Asset Management,
Delivery
Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0075) Washington, DC 20503.

6. FROM TRANSFEROR: 7. TO TRANSFEREE: RECEIVED DATE

Company Name and Complete Address Company Name and Complete Address

IMPORTED DUTY PAID, DESIGNATED MERCHANDISE OR DRAWBACK PRODUCT

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

21. Contact Name and Address PREPARER 20. Total

Phone Number Ext.

FAX Number

CBP Form 7552 (07/08)

 22. 23. 24. 25. 26.
Quantity & Description Date(s) of Description of Articles Manufactured or Produced Quantity & Date Delivered
of Merchandise Used Manufacture (Include Part/Style/Serial Numbers) Unit of
(MM/DD/YYYY) Measure

27. 28. 29.

Duty Available on Manufacture Articles Drawback Available Per Unit of Measure Factory Location
(Total of Duties in Block 20) on Manufactured Article

30. Exhibits to be attached for the following:

Relative Petroleum Domestic Tax Piece Goods Waste Recycled Harbor Maintenance Fee
Value Paid Alcohol Calculation 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 Officer of Corporation Broker with Power of Attorney

Printed Name and Title Signature and Date

CBP Form 7552 (07/08)