OMB No. 1651-0098 
                                    DEPARTMENT OF HOMELAND SECURITY                                        Exp. 04-30-2020
                                    U.S. Customs and Border Protection

                                  NORTH AMERICAN FREE TRADE AGREEMENT 
                                           CERTIFICATE OF ORIGIN
                                                 19 CFR 181.11, 181.22
1. EXPORTER NAME, ADDRESS AND EMAIL                         2. BLANKET PERIOD

                                                            FROM (mm/dd/yyyy)

                                                            TO (mm/dd/yyyy)
TAX IDENTIFICATION NUMBER:
3. PRODUCER NAME, ADDRESS AND EMAIL                         4. IMPORTER NAME, ADDRESS AND EMAIL

TAX IDENTIFICATION NUMBER:                                  TAX IDENTIFICATION NUMBER:
                                                                      6.     7.                                 10.
                           5.                                  HS TARIFF     PREFERENCE 8.       9.             COUNTRY 
                    DESCRIPTION OF GOOD(S)                  CLASSIFICATION   CRITERION  PRODUCER NET COST  OF ORIGIN
                                                               NUMBER

I CERTIFY THAT: 
•  THE INFORMATION ON THIS DOCUMENT IS TRUE AND ACCURATE AND I ASSUME THE RESPONSIBILITY FOR PROVING SUCH  
  REPRESENTATIONS.  I UNDERSTAND THAT I AM LIABLE FOR ANY FALSE STATEMENTS OR MATERIAL OMISSIONS MADE ON OR IN  
  CONNECTION WITH THIS DOCUMENT; 
•  I AGREE TO MAINTAIN AND PRESENT UPON REQUEST,  DOCUMENTATION NECESSARY TO SUPPORT THIS CERTIFICATE, AND TO  INFORM, IN 
  WRITING, ALL PERSONS TO WHOM THE CERTIFICATE WAS GIVEN OF ANY CHANGES THAT COULD AFFECT THE ACCURACY OR VALIDITY  OF 
  THIS CERTIFICATE; 
•  THE GOODS ORIGINATED IN THE TERRITORY OF ONE OR MORE OF THE PARTIES, AND COMPLY WITH THE ORIGIN REQUIREMENTS 
  SPECIFIED FOR THOSE GOODS IN THE NORTH AMERICAN FREE TRADE AGREEMENT AND UNLESS SPECIFICALLY EXEMPTED IN ARTICLE  
  411 OR ANNEX 401, THERE HAS BEEN NO FURTHER PRODUCTION OR ANY OTHER OPERATION OUTSIDE THE TERRITORIES OF THE  
  PARTIES; AND
• THIS CERTIFICATE CONSISTS OF      PAGES, INCLUDING ALL ATTACHMENTS.
   11a.  AUTHORIZED SIGNATURE                               11b. COMPANY

   11c. NAME                                                11d. TITLE
11.
   11e. DATE (mm/dd/yyyy) 11f. TELEPHONE NUMBERS                             11g. EMAIL
                          (Voice)                (Facsimile)

 CBP Form 434 (11/16)                                                                                      Page 1 of 2

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  1651-0098.  The 
estimated average time to complete this application is 2 hours. If you have any comments regarding the burden estimate you can write to U.S. Customs and 
Border Protection, Office of Regulations and Rulings, 90 K Street, NE., Washington DC 20229.     

          NORTH AMERICAN FREE TRADE AGREEMENT CERTIFICATE OF ORIGIN INSTRUCTIONS 
For purposes of obtaining preferential tariff treatment, this document must be completed legibly and in full by the exporter and 
be in the possession of the importer at the time the declaration is made. This document may also be completed voluntarily by 
the producer for use by the exporter. Please print or type:
FIELD 1:         State the full legal name, address (including country), email and legal tax identification number of the exporter. Legal taxation number is: in 
          Canada, employer number or importer/exporter number assigned by Revenue Canada; in Mexico, federal taxpayer's registry number  (RFC); 
          and in the United States, employer's identification number or Social Security Number. 
FIELD 2:         Complete field if  the Certificate covers multiple shipments of  identical goods as described in Field #5 that are imported into a NAFTA country for 
          a specified period of up to one year (the blanket period). "FROM" is  the date upon which Certificate becomes applicable to the good covered by 
          the blanket Certificate (it may be prior to the date of signing this Certificate). "TO" is the date upon which the blanket period expires. The 
          importation of a good for which preferential treatment is claimed based on this Certificate must occur between these dates. 
FIELD 3:         State the full legal name, address (including country), email and legal tax identification number, as defined in Field #1, of the producer. If more 
          than one producer's good is included on the Certificate, attach a list of additional producers, including the legal name, address (including country) 
          and legal tax identification number, cross-referenced to the good described in Field #5. If you wish this information to be confidential, it is 
          acceptable to state "Available to CBP upon request". If the producer and the exporter are the same, complete field with "SAME". If the producer 
          is unknown, it is acceptable to state "UNKNOWN". 
 FIELD 4:        State the full legal name, address (including country), email and legal tax identification number, as defined in Field #1, of the importer. If the 
          importer is not known, state "UNKNOWN"; if multiple importers, state "VARIOUS". 
 FIELD 5:        Provide a full description of each good. The description should be sufficient to relate it to the invoice description and to the Harmonized System 
          (H.S.) description of the good. If the Certificate covers a single shipment of a good, include the invoice number as shown on the commercial 
          invoice. If not known, indicate another unique reference number, such as the shipping order number. 
FIELD 6:         For each good described in Field #5, identify the H.S. tariff classification to six digits. If  the good is subject to a specific rule of origin in Annex 
          401 that requires eight digits, identify to eight digits, using the H.S. tariff classification of the country into whose territory the good is imported. 
FIELD 7:         For each good described in Field #5, state which criterion (A through F) is applicable. The rules of origin are contained in Chapter Four and 
          Annex 401. Additional rules are described in Annex 703.2 (certain agricultural goods), Annex 300-B, Appendix 6 (certain textile goods) and 
          Annex 308.1 (certain automatic data processing goods and their parts). NOTE: In order to be entitled to preferential tariff treatment, each 
          good must meet at least one of the criteria below.  
Preference Criteria
A       The good is "wholly obtained or produced entirely" in the territory of one or more of the NAFTA countries as referenced in Article 415. Note: The 
 purchase of a good in the territory does not necessarily render it "wholly obtained or produced". If the good is an agricultural good, see 
 also criterion F and Annex 703.2. (Reference: Article 401(a) and 415)  
B       The good is produced entirely in the territory of one or more of the NAFTA countries and satisfies the specific rule of origin, set out in Annex 401, 
 that applies to its tariff classification. The rule may include a tariff classification change, regional value-content requirement, or a combination 
 thereof. The good must also satisfy all other applicable requirements of Chapter Four. If the good is an agricultural good, see also criterion F and 
 Annex 703.2. (Reference: Article 401(b))  
C       The good is produced entirely in the territory of one or more of the NAFTA countries exclusively from originating materials. Under this criterion, 
 one or more of the materials may not fall within the definition of "wholly produced or obtained", as set out in article 415. All materials used in the 
 production of the good must qualify as "originating" by meeting the rules of Article 401(a) through (d). If the good is an agricultural good, see also 
 criterion F and Annex 703.2. Reference: Article 401(c).  
D       Goods are produced in the territory of one or more of the NAFTA countries but do not meet the applicable rule of origin, set out in Annex 401, 
 because certain non-originating materials do not undergo the required change in tariff classification. The goods do nonetheless meet the regional 
 value-content requirement specified in Article 401(d). This criterion is limited to the following two circumstances: 
          1.      The good was imported into the territory of a NAFTA country in an unassembled or disassembled form but was classified as an assembled 
                   good, pursuant to H.S. General Rule of Interpretation 2(a), or 
          2.      The good incorporated one or more non-originating materials, provided for as parts under the H.S., which could not undergo a change in 
             tariff classification because the heading provided for both the good and its parts and was not further subdivided into subheadings, or the 
                   subheading provided for both the good and its parts and was not further subdivided. 
          NOTE: This criterion does not apply to Chapters 61 through 63 of H.S. (Reference: Article 401(d)) 
E       Certain automatic data processing goods and their parts, specified in Annex 308.1, that do not originate in the territory are considered originating 
 upon importation into the territory of a NAFTA country from the territory of another NAFTA country when the most-favored-nation tariff rate of the 
 good conforms to the rate established in Annex 308.1 and is common to all NAFTA countries. (Reference: Annex 308.1)  
F       The good is an originating agricultural good under preference criterion A, B, or C above and is not subject to a quantitative restriction in the  
 importing NAFTA country because it is a "qualifying good" as defined in Annex 703.2, Section A or B (please specify). A good listed in Appendix 
 703.2B.7 is also exempt from quantitative restrictions and is eligible for NAFTA preferential tariff treatment if it meets the definition of "qualifying 
 good" in Section A of Annex 703.2. NOTE 1: This criterion does not apply to goods that wholly originate in  Canada or the United States 
 and are imported into either country. NOTE 2: A tariff rate quota is not a quantitative restriction.
FIELD 8:        For each good described in Field #5, state "YES" if you are the producer of the good. If you are not the producer of the good, state "NO" followed 
 by (1), (2), or (3), depending on whether this certificate was based upon: (1) your knowledge of whether the good qualifies as an originating 
 good; (2) your reliance on the producer's written representation (other than a Certificate of Origin) that the good qualifies as an originating good; 
 or (3) a completed and signed Certificate for the good, voluntarily provided to the exporter by the producer.  
FIELD 9:        For each good described in field #5, where the good is subject to a regional value content (RVC) requirement, indicate "NC" if the RVC is 
 calculated according to the net cost method; otherwise, indicate "NO".  If the RVC is calculated over a period of time, further identify the 
 beginning and ending dates (MM/DD/YYYY) of that period. (Reference: Article 402.1, 402.5).  
FIELD 10:      Identify the name of the country ("MX" or "US" for agricultural and textile goods exported to Canada; "US" or "CA" for all goods exported to 
 Mexico; or "CA" or "MX" for all goods exported to the United States) to which the preferential rate of CBP duty applies, as set out in Annex 302.2, 
 in accordance with the Marking Rules or in each party's schedule of tariff elimination. 
                       For all other originating goods exported to Canada, indicate appropriately "MX" or "US" if the goods originate in that NAFTA country, within the 
 meaning of the NAFTA Rules of Origin Regulations, and any subsequent processing in the other NAFTA country does not increase the 
 transaction value of the goods by more than seven percent; otherwise indicate "JNT" for joint production. (Reference: Annex 302.2)  
FIELD 11:      This field must be completed, signed, and dated by the exporter. When the Certificate is completed by the producer for use by the exporter, it 
 must be completed, signed, and dated by the producer. The date must be the date the Certificate was completed and signed.
CBP Form 434 (11/16)                                                                                                                  Page 2 of 2