CUSMA $($Canada $/$ US $/$ Mexico$)$

CERTIFICATION OF ORIGIN

USMCA $($US $/$ Mexico $/$ Canada$)$

T$-$MEC $($M$$xico $/$ Estados Unidos $/$ Canad$)$

$1.$ The Certifier of the goods is the $($choose one$)$ Importer, Exporter or Producer

$2.$ Certifier$$s Name and Address $($including country$)$: $3.$ Exporter$$s Name, Address $($including country$),$ Telephone Number, Email

Address:

$4.$ Producer$$s Name and Address $($including country$),$ Telephone Number,

Email Address:

$5.$ Importer$$s Name, Address, Telephone Number, Email Address:

$6($a$)$

Part # $/$ SKU $/$ Description of Good$($s$)$

$6($a$)$

Classification

Number $6$

Digits

$6($b$)$ Invoice

Number $($for single

shipment$)$ or

indicate Blanket

Period in Field $8$

$7.$

Origin

Criteria

$8.$

Blanket

Period

$($Up to

One Year$)$

Country

of Origin

I certify that:

$$ the information on this document is true and accurate and I assume the responsibility for proving such representations.

$$ I agree to maintain, and present upon request, documentation necessary to support this Certification.

$$ the goods meet the Chapter $4$ Rules of origin and $/$ or specific rules of origin of Annex $4$B$.$

$$ this Certificate consists of pages, including all attachments.

$9$a$.$ Authorized Signature: $9$b$.$ Company:

$9.9$c$.$ Name $($Print or type$)$: $9$d$.$ Title:

$9$e$.$ Date: $($Telephone Number$)($Email