COMBINATION: INVOICE - DECLARATION BY FOREIGN SHIPPER

FOR CUSTOMS CLEARANCE BY

EXPORTER, SELLEREXPORTATEUR, VENDEUR

PRODUCER OF GOODS (IF DIFFERENT THAN EXPORTER)FABRICANT DES MARCHANDISES (SI AUTRE QUE L’EXPORTATEUR)

BUYER (IF DIFFERENT THAN CONSIGNEE)ACHETEUR (SI AUTRE QUE LE DESTINATAIRE)

SHIPPED TOEXPÉDIÉ À

IRS NUMBERIRS NUMBER

INVOICE UNIT QTY.QTÉ UNITAIRE

INVOICE UNIT PRICEPRIX UNITAIRE

INVOICE TOTALTOTAL DE LA FACTURE

L 10 EX 1/00

INVOICE / FACTURE

PREPARER (IF OTHER THAN EXPORTER)PRÉPARATEUR (SI AUTRE QUE L’EXPORTATEUR)

NAME OF RESPONSIBLE EMPLOYEE OF EXPORTERNOM DE L’EMPLOYÉ RESPONSABLE CHEZ L’EXPORTATEUR

To the best of the knowledge and belief of the preparer this invoice is true andcomplete and discloses the true prices, values, quantities, rebates, drawbacks, fees,commissions, royalties and any goods or services provided to the seller either free orat a reduced cost.

MARKS AND NUMBERSMARQUES ET NUMEROS

NUMBER AND KIND OF PACKAGESNOMBRE ET CATÉGORIE DE COLIS

SHIPPING WEIGHTPOIDS À L’EXPÉDITION

PARTIES TO THIS TRANSACTION ARELES TRANSACTIONNAIRES SONT

U.S. DUTY / BROKERAGE FOR ACCOUNT OFDROITS DE DOUANE/COURTAGE É.-U. POUR LE COMPTE DE:

COUNTRY OF FINAL DEST. (IF OTHER THAN U.S.A.)PAYS DE DESTINATION FINALE (SI AUTRE QUE LES É.-U.)

RELATEDASSOCIÉS

NOT RELATEDNON ASSOCIÉS

FREIGHT AMOUNT INCLUDEDMONTANT DU FRET COMPRIS

FREIGHT AMOUNT TO BORDERMONTANT DU FRET À LA FRONTIÈRE

COUNTRY ORIGIN OF GOODS

:

PAYS D’ORIGINEDES MARCHANDISES

EXPORTER / EXPORTATEUR

SHIP TO CONSIGNEE / EXPÉDIER AU DESTINATAIRE

OTHER (SPECIFY) / AUTRE

BROKERAGECOURTAGE

FREIGHTTRANSPORT

DUTYDROITS

ABOVE PRICES INCLUDELES PRIX CI-DESSUS COMPRENNENT:

DECLARATION BY FOREIGN SHIPPER (To be completed only when the goods described above are of U.S. origin and their value exceeds $2000.00)

I

or manufacture of the United States: That they were exported from the United States from the port of

that they are returned without having been advanced in value or improved in condition by any process of manufacture or other means.

declare that the articles herein specified are to the best of my knowledge and belief, the growth, produce

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on or about

SHIPPER SIGNATUREDATESIGNED

DESCRIPTION OF GOODSDESCRIPTION DES MARCHANDISES

SIX DIGIT H.S. NUMBERNUMÉRO DE SIX CHIFFRES DU S.H.

SHIPMENT REFERENCE: