Free CBP Form 3495 - Application for Exportation of Articles Under Special Bond - Federal

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
19 CFR 10.38

Form Approved OMB No. 1651-0004 Exp. 12-31-2010

APPLICATION FOR EXPORTATION OF ARTICLES UNDER SPECIAL BOND
TO CBP PORT DIRECTOR
1. TO: CBP Port Director (Address) 2. FROM: (Name and Address of Importer or Agent)

ATTACH COPY OF EXPORT INVOICE DESCRIBING ARTICLES TO BE EXPORTED
3. Name of Exporting Carrier 4. Date of Departure 8. Entry Number 11. Signature of Importer or Agent 5. Country of Origin 6. No. of Export Packages 9. Date Bonded Period Expires 12. Date

7. Port of Entry 10. Date Articles Available for CBP Examination

Date

NOTICE TO IMPORTER TO DELIVER ARTICLES TO BE EXAMINED AND IDENTIFIED FOR EXPORTATION
13. Place of CBP Examination Date

(FOR CBP USE ONLY)

14. Date

15. CBP PORT DIRECTOR BY:

REPORT OF EXAMINATION
16. The articles covered by this application have been examined and agree with the invoice in content and No. of export pkgs. and are approved for export. 17. No. of Export Packages 18. Date of Delivery for Exportation 19. Marks and Numbers on Export Packages

20. The articles covered by this application do not agree with the invoice in content or in number of packages as follows

21. SIGNATURE OF EXAMINING CBP OFFICER

22. DATE

23. Home of Exporting Conveyance (Vessel, Railroad, Airline and Flight Number) 24. Date of Departure

REPORT OF EXPORTATION

25. Manifest No.

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0004. The estimated average time to complete this application is 8 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

26. SIGNATURE OF CBP OFFICER

(CBP officer must return one copy of this form to port of origin upon exportation.)

(Previous Editions are Obsolete)

CBP Form 3495 (06/09)