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I, ______________________________________________________(name), declare that the articles listed below and covered by the entry to which this declaration relates are wholly the growth, product, or manufacture of a single foreign territory or country or insular possesion of the United States as identified below. I declare that the information set forth in the declaration is correct and true to the best of my information, knowledge and belief. ______________________________________(country)

Date:________________________________________ Name:________________________________________ Signature:___________________________________ Title:_______________________________________ Company:_____________________________________ Address:_____________________________________ *Country when used in this declaration includes territories and insular possessions of the United States. The country will be indetified in the above declaration by the alphabetical designation appearing next to the named country.