Combination Invoice Form

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COMBINATION INVOICE - DECLARATION BY FOREIGN SHIPPER
NAME OF
SHIPPER,
EXPORTER,
SELLER
—
REFERENCE NOS
ADDRESS
ADDRESS
TELEPHONE
#
INVOICE DATE
CONSIGNEE
—
ADDRESS
ADDRESS
BUYER
—
ADDRESS
ADDRESS
IRS#
IRS#
PAGE OF PAGES
OF
BILL U.S. DUTY, MPF, AND/OR BROKERAGE TO:
ACCOUNT NUMBER:
អ CONSIGNEE
អ BUYER
PORT OF ENTRY
អ SHIPPER
U.S. DUTY AND BROKERAGE
INCLUDED IN INVOICE VALUE:
PLACE OF LADING (CITY/PROVINCE)
អ YES
អ NO
TERMS OF SALE, PAYMENT, AND DISCOUNT
អ PLANT
F.O.B.
LOCAL CARRIER
BILL OF LADING #:
EXPORTING CARRIER
IS FREIGHT INCLUDED IN INVOICE VALUE?
អ NO
អ YES AMOUNT
អ DESTINATION, OR
DERINGER TO PROVIDE CARGO INSURANCE?
DATE OF SALE
អ YES
CURRENCY
អ NO
SHIPMENT PRICING SUBJECT TO FIRST PARTIES TO THIS TRANSACTION ARE:
SALE PRINCIPLE UNDER 19 USC 1401a.
អ RELATED
អ YES
CURRENCY
អ NOT RELATED
SHIPPING WEIGHT:
DECLARATION BY FOREIGN SHIPPER (COMPLETE IF GOODS DESCRIBED BELOW ARE OF U.S. ORIGIN AND VALUE EXCEEDS $1000.00)
អ KGS
I, __________________________________ , DECLARE TO THE BEST OF MY KNOWLEDGE AND BELIEF THE ARTICLES HEREIN SPECIFIED ARE PRODUCTS OF THE UNITED STATES; THAT
THEY WERE EXPORTED FROM THE UNITED STATES, FROM THE PORT OF ______________________________________________ ON OR ABOUT ____________________________ ,THAT THEY
អ LBS
ARE RETURNED WITHOUT HAVING BEEN ADVANCED IN VALUE OR IMPROVED IN CONDITION BY ANY PROCESS OF MANUFACTURE OR OTHER MEANS.
SIGNATURE ____________________________________________________________________ CAPACITY __________________________________________________________________
COUNTRY OF
MANUFACTURE
OR GROWTH
MARKS AND NUMBERS
NUMBER AND KIND OF PACKAGES
HTS NUMBER
DESCRIPTION OF GOODS
QUANTITY
UNIT PRICE
TOTAL PRICE
0.00
0.00
0.00
0.00
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0.00
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0.00
If the production of these goods involved furnishings, goods, or services to the seller (e.g., assists such as dies, molds, tools, engineering work), and the value is not included in the invoice price, give explanation.
If no assists, state so.
This invoice must specifically state that the applicable duty or fees for ADD/CVD, MPF, HMF, beef, pork, and honey fees are included in the invoice price.
prices, values, quantities, rebates, drawbacks, fees, commissions, royalties, and any goods or services
EXPORT PERMIT NO.
provided to the seller either free or at a reduced cost.
SOFTWOOD LUMBER ONLY
ESTIMATED FREIGHT CHARGE
TO POINT OF EXIT $
0.00
TOTAL
INVOICE VALUE
To the best of my knowledge as the preparer, this invoice is true and complete and discloses true
OR TO DESTINATION $
GIVE NAME AND ADDRESS IF DIFFERENT FROM EXPORTER BOX ABOVE
EXPORT PRICE
CURRENCY
EXPORT CHARGE
CURRENCY
BLANKET IMPORTER DECLARATION ON FILE
អ YES
អ NO
IMPORTER DECLARATION ATTACHED
អ YES
អ NO
I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE AND ON THE CONTINUATION
SHEET(S), IF ANY, IS TRUE AND COMPLETE IN EVERY RESPECT.
DATE
__________________________________________________
SIGNATURE ......................................................................................................
STATUS
SHIPPER AGENT
អ
អ
PAGE OF PAGES
OF
COUNTRY OF
MANUFACTURE
OR GROWTH
MARKS AND NUMBERS
DESCRIPTION OF GOODS
NUMBER AND KIND OF PACKAGES
HTS NUMBER
QUANTITY
UNIT PRICE
TOTAL PRICE
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