Free CBP Form 4455 - Certificate of Registration - Federal

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection CERTIFICATE OF REGISTRATION
19 CFR 10.8, 10.9, 10.68, 148.1, 148.8, 148.32, 148.37 VIA (Carrier) (NOTE: Number of copies to be submitted varies with type of transaction. Inquire at Port Director's office as to number of copies required.) B/L or INSURED NO.

Form Approved. OMB No. 1651-0010 Exp. 08-31-2009 NO.

DATE

NAME, ADDRESS, AND ZIP CODE TO WHICH CERTIFIED FORM IS TO BE MAILED (If Applicable)

ARTICLES EXPORTED FOR: ALTERATION* REPAIR* USE ABROAD REPLACEMENT PROCESSING* OTHER, (specify)

* NOTE: The cost or value of alterations, repairs, or processing abroad is subject to CBP duty. LIST ARTICLES EXPORTED
Number Packages Kind of Packages Description

SIGNATURE OF OWNER OR AGENT (Print or Type and Sign)

DATE

The Above-Described Articles Were: DATE EXAMINED PORT DATE LADEN under my supervision PORT

SIGNATURE OF CBP OFFICER

SIGNATURE OF CBP OFFICER

CERTIFICATE ON RETURN
Duty-free entry is claimed for the described articles as having been exported without benefit of drawback and are returned unchanged except as noted: (use reverse if needed)

SIGNATURE OF IMPORTER (Print or Type and Sign)

DATE

NOTE: Certifying officers shall draw lines through all unused spaces with ink or indelible pencil.
Paperwork Reduction Act Notice: This request is in accordance with the Paperwork Reduction Act. The information to be provided is submitted by importers/ exporters. Completion of this form is mandatory and to your benefit. The estimated average burden associated with this collection of information is 3 minutes per respondent depending on individual circumstances. Comments concerning the accuracy of this burden estimates and suggestions for reducing this burden should be directed to U.S. Customs and Border Protection, Information Services Branch, Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction Project (1651-0010), Washington, DC 20503.

CBP Form 4455 (06/00)