DEPARTMENT OF HOMELAND SECURITY
I request that: (Mark only one code ) 10 Bills, Refunds and Notices of Liquidation Checks for Refunds or Drawback only Bills Only 40 Bills and Notices 34 Checks and Notices
U.S. Customs and Border Protection
20 30
23 24
Bills and Checks Notices of Liquidation only
SPECIAL ADDRESS NOTIFICATION
Note: A Report of Importer
Number (CBP 5106) must be on file for each Importer Number appearing on this form.
be addressed to the undersigned in care of the agent whose Importer Number is shown below whenever it appears as Reference Number on an Entry Summary (CBP 7501) for which I am (my organization is) the Importer of Record. Agent's Name _______________________________________ Agent's Number ________________
(Show hyphens)
My (organization's) Importer No.
(Show hyphens)
______________________________________________ ________
(Signature) (Date)
Principal Member of Firm _____________of the Corp.
(Title)
CBP Form 4811 (10/01)