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U. S. MANUFACTURER'S AFFIDAVIT I, (1)______________________________, declare that the articles herein specified were manufactured by the company indicated below, and they are to the best of my knowledge and belief, the growth, produce, or manufacture of the United States: That they were exported from the United States from the Port of (2)____________________ on or about (3)_______________, 20____. That they are returned without having been advanced in value or improved in condition by any process of manufacture or other means. I further declare that U.S. manufacturer's drawback (4) ( (4) ( ) was claimed* ) was not claimed Item & Description Quantity Value (5)______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ COMPANY OF MANUFACTURE: (6)_____________________________________________________ ADDRESS: (7)______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ SIGNATURE: (8) __________________________________________ __________________________________________ TITLE: (9) __________________________________________ DATE: (10) FILED ON CUSTOMS ENTRY NO. (11)__________________________________ * If U.S. manufacturer's drawback was claimed, please indicate below the amount of drawback received, port and date filed. A38 Rev. 01/14/02 U. S. MANUFACTURER'S AFFIDAVIT INSTRUCTIONS 1. Person's name completing the declaration. 2. Port of Exporting. 3. Today's date. 4. Indicate whether drawback was claimed or not claimed. 5. Item description, quantity and value. 6. Company of manufacture. 7. Company's address. 8. Signature of U.S. party. 9. Title. 10. Today's date. 11. Will complete by CHB. A38I Rev. 01/14/02