Importers Statement of Value or the Price Paid in the Form of an Invoice

Not being in possession of a special or commercial seller’s or shipper’s invoice, I request that you accept the statement of value or the price paid in the form of an invoice submitted below:

 Name of shipper      ____________________             Address __________________________________

Name of shipper      _____________________            Address __________________________________

Name of shipper      _____________________           Address __________________________________

Name of shipper      _____________________           Address __________________________________

The merchandise (has) (has not) been purchased or agreed to be purchased by me. The prices, or in the case of consigned goods the values, given below are true and correct to the best of may knowledge and belief, and are based upon (check basis with an “X”):

(a)	The prices paid or agreed to be paid (     ) as per order dated _____________	(d)	Knowledge of the market in the country of exportation (     )
(b)	Advices from exporters by letter (     ) by cable (     ) dated ______________	(e)	Knowledge of the market in the United States if U.S. value (   )
(c)	Comparative values of shipments previously received (     ) dated	(f)	Advices of the District Director of Customs (   )
		(g)	Other (     )

A	B	C	D	E	F	G
Case Marks Numbers	Manufacturer’s item number, symbol or brand	Quantities and full description	Unit purchase price (currency)	Total purchase price (currency)	Unit foreign value	Unit foreign value

Check which of the charges below are, and which are not, included in the prices listed in columns “D” and “E”:

Amount Included Not Included                                                                               Amount Included Not Included

Packing ________________________________                                          Lighterage __________________________________

Cartage ________________________________                                           Ocean freight ________________________________

Inland freight ­___________________________                                            U.S. duties __________________________________

Wharfage and loading abroad ______________                                             Other charges (identify by name and amount _______

___________________________________________

Country of origin ________________________                                           Total _______________________________________

If any other invoice is received, I will immediately file it with the District Director of Customs.

Date __________________                            Signature of person making invoice _______________________________________

Title and firm name _______________________________________