MANUFACTURER’S AFFIDAVIT & CERTIFICATE OF ORIGIN

Manufacturer Name / Address:

We hereby, affirm and declare that the products listed below: (circle one):

A. Are Wholly, including all components, the growth, produce or manufacture of the listed country

OR: B. Are substantially transformed by us through a process of manufacture (other than simple

combining, re packaging, etc.) into its current FORM, FIT and FUNCTION listed below

Product Name Part # Countries of Manufacture C. I declare that: (circle one)

1. No U.S. Customs Drawback was claimed by us. 2. U.S. Customs Drawback was claimed and we have listed the amounts stated

below: D. Certification: I certify that I am personally familiar with the facts stated above and will

assist GEPS if further information is required. Printed Name & Title Signature Date

Instructions for completing Manufacturer’s Affidavit: The Manufacturer’s Affidavit is to be filled out by a party knowledgeable of the Manufacturing of the commodity, or who can access the Manufacturing records. Indicate in A or B if the commodity was wholly Manufactured or substantially transformed by the Manufacturer. List Product name(s) and Part Number(s) for all commodities that were US Manufactured. Section C&D should be completed by a party knowledgeable of any Drawback program that the US Manufacturer participates in. (The Manufacturer’s Broker may be able to assist in making this determination.) **For GE Manufactured commodities, all drawback verification should be sent to the Customs Compliance Manager, Stephen Brenon, for Drawback verification.