PROCEDURE Supplier Guide for U.S. Imports

PROCEDURE ndash Supplier Guide for US Imports

Document Sector Corporate Region United States

Document

IMP-USA-ENT-121

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Owner Corporate Trade Compliance

Department

Trade Compliance Functional Area IMPORT

Specific Owner Alisa Crooks

INTERNALEXTERNAL DOCUMENT EXTERNAL DOCUMENTS TO BE DISTRIBUTED IN PDF FORMAT ONLY

Printed copies valid only on the date of print PRINT DATE 6122018

Corporate Policy It is Ingersoll Randrsquos policy to comply fully with the Customs laws regulations and policies of all countries where it does business Ingersoll Rand recognizes that the United States government and the government of other countries have laws regulations and policies which control the international movement (import and export) of goods technology and data Ingersoll Rand further recognizes the importance of compliance with these laws regulations and policies Failure to comply may result in severe penalties to Ingersoll Rand and or individual employees including monetary penalties adverse publicity loss of import export privileges delay or seizure of shipments and in extreme cases criminal penalties (fines and jail terms)

Purpose This Supplier Guide for US Imports is in place to ensure efficient and timely delivery of cargo from international supply points to Ingersoll Rand locations within the United States These procedures cannot be interpreted as a substitute for compliance with applicable US Government regulations Failure to comply with these requirements could result in unexpected delays unnecessary costs finespenalties inspections andor seizure of inbound shipments for non-regulatory compliance

Scope This policy applies to all US imports The most current version of the Supplier Guide for US Imports is located on httpcompanyingersollrandcomircorpendiscover-usdoing-business-with-usfor-ingersoll-rand-suppliershtml

Shipping Advice For shipments to the US when Ingersoll Rand is the Importer of Record (IOR) we require

Email to appropriate US Customs Broker to notify shipment details including Commercial invoice in Excel format Packing List in Excel format Booking details ISF Arrival Notice Transportation documentation Bill of Lading Airway Bill of Lading Other documents if applicable Mill Certificate EPA DOT Anti-Dumping Worksheet

Commercial Invoice Requirements

Must be in English

Must be in Excel format

Must be legible complete and accurate

For SAMPLE shipments with no Ingersoll Rand part number(s) please email the following for parts data PRIOR to shipment irtradedataircocom

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Department

See Commercial Invoice EXAMPLE below

Commercial Invoice

TEMPLATE1xls

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US BROKER NOTIFY PARTIES

NON-US Suppliers (other than CanadaMexico) Expeditors International Customs Brokers Attn US Imports Desk Email itsimports-cltexpeditorscom Telephone 704-329-0303 Web site wwwexpeditorscom

Canadian Suppliers Expeditors International Customs Brokers Attn US Imports Desk Email1 preadvance-bufexpeditorscom Email2 arrivalnotificationexpeditorscom Telephone 734-942-5870

Mexican Suppliers ndash Laredo TX crossing Expeditors International Customs Brokers Attn US Imports Desk Email Electronicslrdexpeditorscom Telephone 956-712-1613

Mexican Suppliers ndash El Paso TX crossing Expeditors International Customs Brokers Attn US Imports Desk

Email1 ELP-Brokerageexpeditorscom Email2 JavierGarciaexpeditorscom Telephone 915-771-6400

Puerto Rico Suppliers ndash Expeditors International Customs Brokers Attn US Imports Desk Email customs-sjuexpeditorscom Telephone 787-750-7500

COURIER SHIPMENTS

UPS small parcelpackage shipments UPS Small Parcel Services Customs Brokers Attn USA Imports Desk Email upsusingersollrandupscom Telephone 502-485-2623

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Department

Product Marking All products or their individual packaging must be marked in English with ISO country of origin the country where the good was manufactured andor assembled The country of shipment is not necessarily the country of origin Origin marking must be in English and be clear conspicuous legible and permanent to indicate to the ultimate purchaser in the United States the English name of the country of origin of the merchandise

Assists US Customs requires any assists to be reported at the time of import filing and can be added to one shipment or a number of shipments for a specific period of time The foreign supplier must first identify any item that was provided free of charge or below market value for use in the production of product for Ingersoll Rand Assists can include machinery or parts molds raw materials

IR Document GPO SW 0015 Supplier Assists-US Customs

GPO SW 0015 -

Supplier Assists-US Customsdocx

IR intranet BOS site where above-referenced document is located httpshomeingerrandcomsitesbosondemandListsPlaybook20ItemDispFormaspxID=36ampk=global20procurement

Product Information Requests and Records Upon request our valued Suppliers will provide Ingersoll Rand with all information and records relating to the purchased products that may be necessary for Ingersoll Rand to (a) fulfill any Customs obligations origin marking or labeling requirements (b) claim preferential duty treatment under applicable trade preference regimes and (c) participate in any duty deferral or free trade zone programs of the country of import Ingersoll Rand is legally required to maintain certain documentation and specific data related to products imported into the United States This documentation may help substantiate key compliance elements such as the harmonized tariff classification and country of origin of the imported products In order to maintain the data Ingersoll Rand may send suppliers solicitation requests on a regular basis These requests may include but are not limited to any of the following NAFTA CAFTA GSP ChileKoreaAustraliaColombia-US Free Trade Agreements Certificate of Origin or Manufacturerrsquos AffidavitDeclaration or Certificate of Origin requests

Export Packaging Requirements All wooden packaging materials (WPM) must be ISPM15 compliant All WPM must be properly marked to indicate either heat treatment or methyl bromide treated and marked with the IPPC certification Wood packing material is defined as wood or wood products (excluding paper products such as corrugated paper cartons) used in

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supporting protecting or carrying a commodity (includes tonnage) Wooden packing materials include Pallets crates boxes packing blocks drums cases skids and pieces of wood used to support or brace cargo US Customs and Border Protection requires all containers transiting via ocean vessel are sealed using ISOPAS 17712 standards For more information on CBPrsquos requirements httpswwwcbpgov Ingersoll Randrsquos Packaging Guideline httpcompanyingersollrandcomircorpendiscover-usdoing-business-with-usfor-ingersoll-rand-supplierspackaging-guidelineshtml

Partnering Government Agencies (PGA) FCC ndash Federal Communication Commissionrsquos Radio Frequency Declaration - All electronic devices such as monitors cameras computers phones recording devices etc must have a completed FCC form 740 included with the shipment documentation See link for form httpstransitionfccgovFormsForm740740pdf FDA ndash Review the Food amp Drug Administration regulations to complete necessary requirements for US importation For imported electronic products subject to radiation control standards completed the attached form httpswwwfdagovRadiation-EmittingProductsElectronicProductRadiationControlProgramdefaulthtm

FDA for Radiation Control Standards

EPA ndash The Environmental Protection Agency requires a Toxic Substance Control Act form to be complete with each import of most chemical goods water samples and products that fall under the jurisdiction of the EPA The EPA also requires an Engine Declaration Form be complete for all imports of engines vehicles and equipment subject to Federal Air Pollution regulations

httpswwwepagovimporting-vehicles-and-enginesepa-standard-form-3520-21-importation-engines-vehicles-and-equipment

httpswwwepagovtsca-inventory

EPA Engine Air Pollution Form

TSCA Statement from

Supplierdoc

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DOT ndash The Department of Transportation requires a Declaration of Motor Vehicles form to be complete with each import of motor vehicles and equipment for motor vehicles httpswwwnhtsagov

DOT Motor Vehicles and Equipment form

Antidumping Requirements

Some commodities imported into the US carry duties assessed in addition to the standard tariff rate of duty called Anti-Dumping or Countervailing Duties Antidumping duty and countervailing duty orders are related to specific commodities from specific countries Currently Ingersoll Rand imports subject to antidumping include httpswwwusitcgovtrade_remedy731_ad_701_cvdinvestigationshtm

ALUMINIUM EXTRUSIONS

IRON PRODUCTS

NON-MALLEABLE CAST IRON PIPE FITTINGS

SEAMLESS REFINED COPPER PIPE and TUBING

STEEL PRODUCTS

TAPERED ROLLER BEARINGS

SOLAR CELLS and PANELS If the commodity being imported into the US contains any of these products COMPLETE THE ATTACHED FORMS

BEARING Products

WORKSHEETdoc

Seamless COPPER

TUBING WORKSHEETdocx

ALUMINUM Extrusion

WORKSHEETdocx

Importer Security Filing (ISF) Requirements

Required for ALL OCEAN shipments to the US and Puerto Rico US Customs has implemented additional security requirements (10+2 or the Importer Security filing (ISF)) requiring shippers report 10 data elements for authorization prior to loading goods on a vessel bound for the United StatesPuerto Rico These regulations became effective January 26 2009 and failure to comply will lead to penalties of $5000 USD per occurrence and up to $10000 USD per shipment

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Suppliers must provide Ingersoll Randrsquos appointed customs broker Expeditors International with a copy of documentation and complete the ISF form

ISF Form for

SUPPLIER to Completexls

The ISF form must be emailed to Expeditors no less than 72 hours before cargo is loaded onto an ocean vessel Email address clt-isfexpeditorscom

Definitions Anti-dumping duty Selling below home market prices or cost of manufacture with material injury to an US

manufacturer is called dumping Antidumping duties are levied upon further importation of the merchandise

AWBBOL Airway bill or Bill of Lading are negotiable instruments that allow the carrier to transport a merchandise shipment from a shipper to a consignee

CBP US Customs and Border Protection is a federal law enforcement agency of the United States Department of Homeland Security charged with regulating and facilitating international trade collecting import duties and enforcing US regulations including trade drug and immigration laws httpwwwcbpgov

Commercial Invoice Invoice used for shipping purposes Commercial invoice must be in English and value in USD

Country of Origin The country where the goods were originally produced or manufactured The country of origin is NOT necessarily the country from which the goods were shipped

EPA Environment Protection Agency is an independent US government agency that sets and enforces rules and standards that protect the environment and control pollution httpwwwepagovopptimport-export

FCC Federal Communication Commission is an independent US government regulatory agency overseeing all international communications The FCC acts to maintain the standards and consistency among the ever-growing types of media and methods of distribution while protecting the interest of both consumers and businesses httpswwwfccgov

FDA Food and Drug Administration is a regulatory agency of the US Department of Health and Human Services responsible for protecting and promoting public health httpwwwfdagov

HTS Harmonized Tariff Schedule is a 10-digit alphanumeric code assigned to all commodities entering the United States The HTS coding system was established by the World Customs Organization (WCO)

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Department

Incoterms International Commercial Terms that identify the trade contract responsibilities and

liabilities between buyer and seller IOR Importer of Record is the owner or purchaser of the goods who is liable for the payment

of duties or an authorized agent acting on the importerrsquos behalf ISF Importer Security Filing or 10+2 This is a pre-alert to US Customs that identifies

specific data elements prior to loading at the foreign port for all ocean shipments Packing List Provides a detail of each item contained within the shipment the piece count and in

which package each item is contained Also identifies the number of packages with the gross and net weight of each

PGA Partnering Government Agency WPM Wood Packing Materials

Contact Information Ingersoll Rand US Import Compliance Team please email

irimportcomplianceircocom

For Logistics and Transportation inquiries please email

GlobalProcurementircocom Revision History

Revision Date Description of Change Modified By

Original 6052015 Original document released Alisa Crooks

Revision1 6042018 Document revised Beth Wedgworth

Release 6132018 Document released Beth Wedgworth

Extruded Aluminum Worksheet

Supplier _________________

MANUFACTURE ADDRESS ___________________________________________________

_________________________________________________________________________

Exporter Shipper Name ___________________________________________________

Completed By (Print NAME) _______________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

BEARING Worksheet

Bearing Manufacturer______________________________________________________________________

Country of Origin______________________________________________________________________

Manufacturer Address______________________________________________________________________

(If Manufacturer is different from ExporterShipper)

______________________________________________________________________

Part Number______________________________________________________________________

Type of Bearing Ball ______________

(Select one) Roller______________

Combination BallRoller or RollerRoller______________

Housed______________

Plain Shaft______________

Parts of Bearings______________

If Ball Bearing Integral Shaft ndash provide outside diameter in mm________________________

(Select all that apply)Thrust________________________

Linear________________________

Angular Contact ndash specify if wheel hub unit________________________

- is wheel hub flanged

Radial - provide outside diameter in mm________________________

- multiple rows of balls indicated double triple

- maximum of full capacity type________________________

Other - (clutch release bearings ball cage assemblies

sold as complete unit etc specify type________________________

Are bearings ungrounded________________________

Page 1 of 3

If Roller Bearing Spherical________________________

(Select all that apply) Tapered - provide outside diameter of cup in mm________________________

- cup and cone assemblies shipped together________________________

- cup and cone assemblies shipped separately________________________

- wheel hub unit________________________

- is wheel hub unit flanged________________________

BEARING Worksheet (Contrsquod)

Needle ndash provide dimensions (LxW) of rolling element in mm____________________

Cylindrical ndash provide dimension (LxW) of rolling element in mm____________________

If Combination BallRoller or Roller Roller

(Select one)Ball Spherical Roller_____________________

Ball Needle ndash provide dimensions of rolling element__________________________

Ball Cylindrical Roller_____________________

Needle Roller Cylindrical Roller_____________________

Other ndash specify the particular elements presents_____________________

If Housed Bearing Type of Housing ndash flange take up cartridge hangar units or

or other type_____________________

Type of Bearing Incorporated ndash Indicate information specified

above for the roller element of that particular bearing_____________________

If Plain Shaft Bearing

(Select one)Whether bearings are housed or unhoused_____________________

Whether bearings are spherical or not_____________________

Page 2 of 3

If Bearings Parts What type bearing item is a part of _____________________

(Select all that apply)Identify of part ndash cups tapered roller ball ring cage etc_____________________

For balls intended use ndash ball bearings CV joints etc_____________________

For needles ndash provide dimensions (length and diameter of

roller element in mm_____________________

Finishing Process Indicate if bearings parts are not completely finished ie

green ungrounded etc_____________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

US Departmentof TransportationNational HighwayTraffic SafetyAdministration

mdash D E C L A R A T I O N mdashImportation of Motor Vehicles and Motor Vehicle Equipment Subject to

Federal Motor Vehicle Safety Bumper and Theft Prevention Standards

OMB No 2127-0002Public Law 100mdash56249 USC Chap 301

PORT OF ENTRY CUSTOMS ENTRY NO ENTRY DATE

MAKE OF VEHICLE MODEL YEAR VEHICLE IDENTIFICATION NUMBER (VIN) | | | | | | | | | | | | | | | |

REGISTERED IMPORTER NAME AND NHTSA REGISTRATION NUMBER (Required when Box 3 is checked) VEHICLE ELIGIBILITY NO (Box 3)

DESCRIPTION OF MERCHANDISE IF MOTOR VEHICLE EQUIPMENT

NAME OF IMPORTER (Please type)

(Please type)

IMPORTERS ADDRESS (Street City State Zip Code)

NAME OF DECLARANT DECLARANTS ADDRESS

DECLARANTS CAPACITY DECLARANTS SIGNATURE DATE SIGNED

HS-7 (Rev 05-2006)OVER

75124 ndashM34d

CUSTOMS PORT CODE

1 The vehicle is 25 or more years old or the equipment item was manufactured on a date when no applicable Federal Motor Vehicle Safety Standard or Theft Prevention Standard was in effect

Date of manufacture ____________________[5915(i)]

2A The vehicle or equipment item conforms to all applicable Federal Motor Vehicle Safety Standards (or the vehicle does not conform solely because readily attachable equipment items that will be attached to it before it is offered for sale to the first purchaser for purposes other than resale are not attached) and Bumper and Theft Prevention Standards and bears a certification label or tag to that effect permanently affixed by the original manufacturer to the vehicle or affixed by the manufacturer to the equipment item or to its delivery container in accordance with applicable National Highway Traffic Safety Administration (NHTSA) regulations [5915(b)]

2B The vehicle was certified by its original manufacturer as conforming to all applicable Canadian motor vehicle safety standards and its original manufacturer confirms that the vehicle conforms to all applicable US Federal Motor Vehicle Safety Bumper and Theft Prevention Standards (or that it conforms to all such standards except for the labeling requirements of Standards Nos 101 and 110 or 120 andor the specifications of Standard No 108 relating to daytime running lamps) and the vehicle is not a salvage motor vehicle a repaired salvage motor vehicle or a reconstructed motor vehicle and I am importing it for personal use [5915(g)]

Attachment Copy of manufacturers confirmation letter

3 The vehicle does not conform to all applicable Federal Motor Vehicle Safety and Bumper Standards but does conform to applicable Federal Theft Prevention Standards but I am eligible to import it because NHTSA has determined that the model and model year of the vehicle to be imported is eligible for importation into the United States and the vehicle is not a salvage motor vehicle or a reconstructed motor vehicle and I have furnished a bond which is attached to this declaration in an amount equal to 150 percent of the entered value of the vehicle as determined by the Secretary of the Treasury If the Administrator of NHTSA determines that the vehicle has not been brought into conformity with all such standards within 120 days after importation then I state that I will deliver such vehicle to the Secretary of Homeland Security for export or abandon it to the United States [5918] and that

a I have registered with NHTSA pursuant to 49 CFR Part 592 and such registration is not suspended and has not been revoked or

b I have executed a contract or other agreement which is attached to this declaration with an importer who has registered with NHTSA and whose registration is not suspended and has not been revoked [5915(f)]

Attachments Copy of DOT Bond and

Copy of Contract with a Registered Importer if applicable

4 The vehicle or equipment does not conform to all applicable Federal Motor Vehicle Safety Bumper and Theft Prevention Standards but is intended solely for export and is labeled for export on the vehicle or equipment item and the outside of any container of the vehicle or equipment item bears a label or tag to that effect [5915(c)]

5 The vehicle or equipment does not conform to all applicable Federal Motor Vehicle Safety Bumper and Theft Prevention Standards but I am eligible to import it because all of the following conditions exista I am a nonresident of the United States and the vehicle is registered in a country other than the

United Statesb I am temporarily importing the vehicle for personal use for a period not to exceed 1 year and will

not sell it during that time andc I will export it not later than the end of 1 year after entry and the declaration contains my passport

number and country of issue [5915(d)]

d Passport No ___________________ Country of Issue ___________________

6 The vehicle does not conform to all applicable Federal Motor Vehicle Safety Bumper and Theft Prevention Standards but I am eligible to import it because all of the following conditions exist

a I am a member of a foreign government on assignment in the United States or a member of the Secretariat of a public international organization so designated under the International Organiza-tions Immunities Act and within the class of persons for whom free entry of motor vehicles has been authorized by the Department of State

b I am importing the vehicle on a temporary basis for my personal use and will register it through the Office of Foreign Missions of the Department of State

c I will not sell the vehicle to any person in the United States other than a person eligible to import a vehicle under this paragraph

d I will obtain from the Office of Foreign Missions of the State Department before departing the United States at the conclusion of a tour of duty an ownership title to the vehicle good for export only and

e I have attached a copy of my official orders [5915(h)(1)] Name of Embassy _______________________________________________

Attachment Copy of Official Orders

7 The vehicle or equipment does not conform to all applicable Federal Motor Vehicle Safety and Bumper Standards but is being imported solely for the purpose of research investigations demonstrations or training or competitive racing events and I state that I will comply with the applicable restrictions on importers of such merchandise as specified in 49 CFR 5917 and I will provide the Administrator with documentary proof of export or destruction not later than 30 days following the end of the period for which the vehicle has been admitted into the United States [5915(j)]

Attachmenta Copy of NHTSA permission letter if the importer is not an original manufacturer of motor vehicles

(or a wholly owned subsidiary thereof) that are certified to conform to all applicable Federal Motor Vehicle Safety Standards (FMVSS) Use on the public roads must be authorized specifically [5916(f )(1) or (2)]

b Importers statement describing the use to be made of the vehicle or equipment item if the importer is an original manufacturer of motor vehicles (or a wholly owned subsidiary thereof) that are certified to conform to all applicable FMVSS If use on the public roads is an integral part of the purpose for which the vehicle or equipment item is imported the statement shall describe the purpose that makes such use necessary state the estimated period of time during which use of the vehicle or equipment item on the public roads is necessary and state the intended means of final disposition (and disposition date) of the vehicle or equipment item after completion of the purpose for which it is imported [5916(f)(3)]

8 The vehicle was not manufactured primarily for use on the public roads and thus is not a motor

vehicle subject to the Federal Motor Vehicle Safety Bumper and Theft Prevention Standards or the equipment item is not a system part or component of a motor vehicle and thus is not an item of motor vehicle equipment subject to the Federal Motor Vehicle Safety Standards [5915(a)]

Attachment Importerrsquos statement substantiating that the vehicle was not manufactured for use on the public roads or that the equipment item was not manufactured for use on a motor vehicle or is not an item of motor vehicle equipment [5916(a)]

9 The vehicle or equipment item requires further manufacturing operations to perform its intended function other that the addition of readily attachable equipment items such as mirrors wipers or tire and rim assemblies or minor finishing operations such as painting and any part of such vehicle that is required to be marked by the Theft Prevention Standard is marked in accordance with that standard [5915(e)]

Attachment For a vehicle a copy of the Incomplete Vehicle Document issued by the incomplete vehicle manufacturer providing guidance on completing the vehicle so that it conforms to all applicable Federal Motor Vehicle Safety Standards (FMVSS) For an equipment item a statement issued by the itemrsquos manufacturer identifying the applicable FMVSS to which the item does not conform and describing the further manufacturing required for the item to perform its intended function [5916(b)]

10 The vehicle does not conform to all applicable Federal Motor Vehicle Safety and Bumper Standards but is being imported solely for the purpose of show and display and I state that I will comply with all applicable restrictions on importers of such vehicles as specified in 49 CFR 5917 [5915(j)]

Attachment Copy of NHTSA Permission Letter

11 The equipment item is subject to the Theft Prevention Standard and is marked in accordance with the requirements of 49 CFR Part 541 [5915(k)]

12 The vehicle does not conform to all applicable Federal Motor Vehicle Safety Bumper and Theft Prevention Standards but I am eligible to import it because all of the following conditions exista I am a member of the armed forces of a foreign country on assignment in the United States b I am importing the vehicle on a temporary basis and for my personal usec I will not sell the vehicle to any person in the United States other than a person eligible to import

a vehicle under this paragraphd I will export the vehicle upon departing the United States at the conclusion of my tour of duty ande I have attached a copy of my official orders [5915(h)(2)]

13 The vehicle does not conform to all applicable Federal Motor Vehicle Safety and Bumper Standards but does conform to applicable Federal Theft Prevention Standards and I am eligible to import it because I am registered with NHTSA pursuant to 49 CFR Part 592 and such registration is not suspended and has not been revoked I have informed NHTSA that I intend to petition or I have petitioned that agency to decide that the vehicle to be imported is eligible for importation and NHTSA has granted me permission in writing to import the vehicle for that purpose If the Administra-tor of NHTSA dismisses my petition or decides that the vehicle is not eligible for importation or if I withdraw my petition or I fail to submit a petition covering the vehicle within 180 days from the date of entry then I state that I will deliver such vehicle unless it is destroyed to the Secretary of Homeland Security for export or abandon it to the United States within 30 days from the date of the dismissal denial or withdrawal of my petition as appropriate or within 210 days from the date of entry if I fail to submit a petition covering the vehicle If the Administrator of NHTSA grants my petition then I state that within 15 days from the date that I am notified of that decision I will furnish a bond in an amount equal to 150 percent of the entered value of the vehicle as determined by the Secretary of the Treasury unless the vehicle is destroyed to ensure that I will bring the vehicle into conformity with all applicable Federal Motor Vehicle Safety and Bumper standards within 120 days from the date the petition is granted or will deliver the vehicle to the Secretary of Homeland Security for export or abandon it to the United States If the vehicle is destroyed then I state that I will furnish NHTSA with documentary proof of that destruction within 15 days from the date that it occurs

Attachment Copy of NHTSA permission letter

EPA Requirements Importers of motor vehiclesengines and nonroad vehiclesenginesequipment must also submit EPA form 3520-1 or 3520-21 to US Customs and Border Protection to identify the basis for importation into the United States and US territories under the laws administered by the United States Environmental Protection Agency For more information please see wwwepagovotaqimportsindexhtm

This form must be prepared by the importer for each imported stationary nonroad or heavy-duty highway engine including engines incorporated into vehicles or equipment Note that references in this form to engines generally include vehicles or equipment if they are subject to equipment-based standards One form per engine or group of engines in a shipment may be used with attachments including all information required to fully describe each engine as below Provide a duplicate form and attachments to the US Customs and Border Protection (CBP) upon request (42 USC 7522 7601 19 CFR 1273 or 1274) This form must be retained for five years from the date of entry (19 CFR 1634) Additional requirements may apply in California NOTE While certain imports require specific written authorization from EPA CBP may request EPA review of importer documentation and eligibility for any import using this form For light-duty motor vehicles highway motorcycles and the corresponding engines use form 3520-1 This form does not apply to aircraft engines

United States Environmental Protection Agency Engine Declaration FormImportation of Engines Vehicles and Equipment Subject to Federal Air Pollution Regulations

US EPA Certification amp Compliance Division 2000 Traverwood Dr Ann Arbor Michigan 48105 (734) 214-4100 importsepagov wwwepagovotaqimports

Identify the type of highway nonroad or stationary engine vehicle or equipment you are importing from the following list of productso A Heavy-duty highway engines (for use in motor vehicles with gross vehicle weight rating above 8500 pounds) See 40 CFR parts 85 and 86o B Locomotives or locomotive engines See 40 CFR parts 1033 and 1068o C Marine compression-ignition engines See 40 CFR part 94 or 40 CFR parts 1042 and 1068 This includes propulsion engines and auxiliary engines installed on marine vesselso D Other nonroad compression-ignition engines See 40 CFR part 89 or 40 CFR parts 1039 and 1068o E Marine spark-ignition engines See 40 CFR parts 1045 and 1068o F Recreational engines and vehicles including snowmobiles off-highway motorcycles all-terrain vehicles and offroad utility vehicles that are subject to the same emission standards as all-terrain vehicles See 40 CFR parts 1051 and 1068 o G Other nonroad spark-ignition engines at or below 19 kW (or at or below 30 kW if total displacement is at or below 1000 cc) See 40 CFR part 90 or 40 CFR parts 1054 and 1068o H Other nonroad spark-ignition engines above 19 kW See 40 CFR parts 1048 and 1068o I Stationary compression-ignition engines See 40 CFR part 60 subpart IIIIo J Stationary spark-ignition engines See 40 CFR part 60 subpart JJJJ

Check one of the following Codes to indicate the provision under which you are importing the engine vehicle or equipment o 1 US certified engine or engine installed in a certified vehicle covered by a valid US EPA certificate of conformity and bearing a US EPA emission control label in English Additional information for Category G engines from 2010 and later model years starting January 1 2010 (see 40 CFR 901007 or 1054690) Exempt from bond___ If not exempt NAIC for bond issuer_____ policy number____________ state of issue__

Permanent Exemptions for Nonconforming Engineso 2 National security Importing a labeled (where applicable) engine subject to the provisions of 40 CFR 1068315(a) For certain types of tactical equipment this exemption may require prior EPA approvalo 3 Manufacturer-owned engine Importing a labeled engine by an engine manufacturer holding a current US EPA certificate of conformity subject to the provisions of 40 CFR 1068315(b) or 851706o 4 Replacement engine Importing a labeled engine by an engine manufacturer holding a current US EPA certificate of conformity subject to the provisions of 40 CFR 1068315(c) or 851714 This exemption does not apply to locomotive engineso 5 Extraordinary circumstanceshardship Importing a labeled engine subject to the provisions of 40 CFR 1068315(d) 851511(c)(2) or 1033620 An EPA letter of approval must be attachedo 6 Hardship for small-volume manufacturers Importing a labeled engine subject to the provisions of 40 CFR 1068315(e) An EPA letter of approval must be attached to this formo 7 Equipment-manufacturer hardship Importing a labeled engine subject to the provisions of 40 CFR 1068315(f) or 1033620 This may also apply to secondary engine manufacturers An EPA letter of approval must be attached to this formo 8 Identical configuration Importing an engine subject to the provisions of 40 CFR 1068315(h) Such an engine must be identical in all material respects to a US-certified version as demonstrated by letter from the engine-manufacturer contact on the CBP list subject to EPA review at CBPsrsquo discretion This exemption does not apply to locomotives or to stationary highway or marine compression-ignition engines The applicable regulations may require that you own the engine for a certain period before and after importationo 9 Ancient engine Importing an engine first manufactured at least 21 years earlier that is still in its original configuration subject to the provisions of 40 CFR 1068315(i) This exemption does not apply to locomotives or to stationary highway or marine engines

Temporary Exemptions for Nonconforming EnginesThe following temporary exemptions apply for importing nonconforming engines EPA requests bonding with the US Customs and Border Protection for the full value of the imported products to make sure you comply with applicable requirementso 10 Repairs or alterations Importing an engine for repair or alteration subject to the provisions of 40 CFR 1068325(a) or 851511(b)(1) An EPA letter of approval must be attachedo 11 Testing Importing an engine for testing subject to the provisions of 40 CFR 1068325(b) or 851511(b)(2) Appropriate labeling is required for some engines and recommended for all engines An EPA letter of approval must be attachedo 12 Display Importing an engine for display subject to the provisions of 40 CFR 1068325(c) or 851511(b)(4) Appropriate labeling is required for some engines and recommended for all engines An EPA letter of approval must be attachedo 13 Export Importing an engine for eventual export subject to the provisions of 40 CFR 1068325(d) or 851709 NOTE The engine andor shipping container must be labeled or tagged to identify them as solely for exporto 14 Diplomatic or military Importing an engine subject to the provisions of 40 CFR 1068325(e) or 851511(d) This exemption is limited to members of the armed forces or personnel of a foreign government on assignment to the US for whom free entry has been authorized in writing by the US Department of State or for members of the armed forces of a foreign country with official orders for duty in the US This exemption does not apply to locomotive or marine compression-ignition engines An EPA letter of approval may be requiredo 15 Delegated assembly Importing a labeled engine for delegated assembly subject to the provisions of 40 CFR 1068325(f) 851713 or 1033630 This exemption does not apply to handheld spark-ignition engines or engines for recreational vehicleso 16 Partially complete engine Importing an engine not yet in its final configuration covered by a certificate of conformity (or an engine that will be installed in a vehicle covered by a certificate of conformity) subject to the provisions of 40 CFR 1068325(g) This also applies to an engine covered by a valid exemption A certificate holder may also import a partially complete engine from its foreign facility to its US facility as described in 40 CFR 1068325(g)

EPA Form 3520-21 (Rev 01-2012) This form approved under OMB control number 2060-0320 until Dec 31 2014 Pg 1 of 2CBP entry no

_ _ _ _______ _Format XXX- 9 999999-9

Importation of Engines Excluded from US EPA Emission Standardso 17 Engine manufactured before emission standards started to apply These engines must generally have already been placed into serviceSee the attached schedule Note that 40 CFR 1068360 disallows importation of new engines not certified to current standards if the model year is more than one year before the year of importationo 18 Competition engine The engine must be used solely for competition subject to the provisions of 40 CFR 1068310(a) or 851511(e) An EPA letter of approval must be attachedo 19 Stationary compression-ignition engine with displacement at or above 30 liters per cylinder or stationary spark-ignition engine above 19 kW that is not designed to run on gasoline or if rich-burn on liquified petroleum gas These stationary engines are subject to EPA emission standards under 40 CFR Subparts IIII and JJJJ but are not required to be certified The engine must be used in a stationary manner See 40 CFR 604219 604248 and 1068310(b) The engine must be labeled as described in 40 CFR 103920 or 104820 as applicable NOTE Stationary engines may be subject to state or local regulationso 20 Underground mining Engine must be used in underground mining and regulated by the Mining Safety and Health Administration (MSHA) See 40 CFR 891 and 10395 see also 30 CFR parts 7 31 32 36 56 57 70 and 75 For compression-ignition engines onlyo 21 Hobby engine Engine must be used to power a reduced-scale model of a vehicle not capable of transporting a person See 40 CFR 1068310(c)

Exemptions for Specific Engine Categories or Other Special Caseso 22 Transition Program for Equipment Manufacturers Importing a piece of equipment subject to the provisions of 40 CFR 89102 or 40 CFR 1039625 and 1039626 (Category D) or 40 CFR 1054625 and 1054626 (Category G 2011 through 2014) Maximum engine power (only for compres-sion-ignition engines) ____________ o kW o HP (or identify the regulatory power category) Exempt from bond____ If not exempt NAIC for bond issuer____________ policy number____________ state of issue___o 23 Personal-use exemption for small spark-ignition engines Importing three or fewer nonroad spark-ignition engines at or below 19 kW for purposes other than resale where the importer has not used this exemption in the previous five years subject to the provisions of 40 CFR 1054630 24 Engine imported by an Independent Commercial Importer recognized by EPA Only for Categories A and D above o 24a For modification under an EPA certificate issued for the specific make model and model year under 40 CFR 851505 89605 or 1039660 o 24b For modification and testing according to 40 CFR 851509 89609 or 1039660 NOTE The imported engine must be at least 6 years old o 24c For precertification testing to obtain an EPA certificate under 40 CFR 851511(b)(3) 89611(b)(3) or 1039660 NOTE CBP bond is required Specify location of storage (required for 24a and 24b) ___________________________________________________________________________ NOTE Under 24a and 24b you may import up to five highway engines and five nonroad engines in a given model year that are certified to standards based on an enginersquos original production year You may import any number of engines certified to standards that apply based on the year the engine is modified See 40 CFR 851503 and 89603o 25 Other exemption Describe the exemption attach EPA approval (if applicable) and identify the regulatory cite

EPA Form 3520-21 (Rev 01-2012) This form approved under OMB control number 2060-0320 until Dec 31 2014 Pg 2 of 2

Declaration of Stationary Nonroad or Heavy-duty Highway Engine Nonroad Vehicle or Equipment or Stationary Equipment

Port code CBP entry no Entry date Engine manufacturer model and serial number of each engine for certified engines or vehicles also identify the engine family name

Identify the engine (or vehicle) build date _____month_______year o on engine o other (explain)

Vehicle or equipment manufacturer model serial number and type of equipment (if applicable)

Names Addresses and Telephone Numbers of Relevant PartiesCertification I certify that I have read and understand the purpose of this form the penalties for falsely declaring information for providing misleading information or for concealing a material fact The information I have provided is correct and all required attachments are appended to this form I authorize EPA Enforcement Officers to conduct inspections or testing permitted by the Clean Air Act I am the owner the importer or an agent of the owner or importer

Signature Printed name Date

Identify the name address phone number and e-mail address for the importer broker and owner as applicable

Importer (required) Broker (optional) Owner (optional)

____Format 9 999 _ _ _ _______ _Format XXX- 9 999999-9

_ _ _ _ _ _ _ _Format mmddyyyy

Penalties (1) Anyone who knowingly makes any false or fraudulent statement or omits or conceals a material fact can be fined up to $295000 or imprisonedfor up to 5 years or both (18 USC 1001) Anyone who illegally imports an engine may be fined up to $37500 per engine (42 USC 7524) and may besubject to forfeiture of the entire importation bond if applicable (40 CFR 1068335 89612 94805) and the engine is subject to seizure by Customs (19 CFR16221) (2) Anyone who distributes in commerce sells offers for sale or introduces into commerce an engine subject to EPA certification requirements butnot covered by a certificate of conformity may be fined up to $37500 per violation (40 CFR 1068101(a) 891006 941106) (3) Any person who circumventsor attempts to circumvent residence-time requirements for stationary engines may be fined up to $37500 per day of violation (40 CFR 1068101(b)(3)891006(a)(5)) Information collection This information is collected to ensure that engines imported into the US conform with applicable emission requirementsResponses to this collection are mandatory (Clean Air Act sections 202 203 and 208) Information submitted to the Agency under a claim of confidentialitywill be safeguarded as described in 40 CFR part 2 The public reporting and recordkeeping burden for this collection of information is estimated to average 30minutes per response An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays acurrently valid OMB control number Send comments on the Agencys need for this information the accuracy of the provided burden estimates and anysuggested methods for minimizing respondent burden including through the use of automated collection techniques to the Director Collection StrategiesDivision US Environmental Protection Agency (2822) 1200 Pennsylvania Ave NW Washington DC 20460 Include the OMB control number in anycorrespondence Do not send the completed form to this address

Schedule for Application of New Emission Standards for Certifying Engines and Vehicles

Engine category Engine subcategory Manufacturing date after whichemission standards start to apply

A Heavy-duty highway engines mdash Model year 1970

B Locomotives or locomotive engines mdash January 1 1973

C Marine compression-ignition engines at orabove 37 kW

Commercial displacement lt 09 Lcyl Model year 2005

Commercial 09 lt displacement lt 25 Lcyl Model year 2004

Commercial displacement gt 25 Lcyl Model year 2007

Recreational displacement lt 09 Lcyl Model year 2007

Recreational 09 lt displacement lt 25 Lcyl Model year 2006

D Other nonroad compression-ignition engines Marine compression-ignition engines Power lt 19 kW January 1 2000

Marine compression-ignition engines 19 kW lt Power lt 37 January 1 1999

Nonroad engines Power lt 19 kW January 1 2000

Nonroad engines 19 kW lt Power lt 37 January 1 1999

Nonroad engines Power gt 560 kW January 1 2000

E Marine spark-ignition engines Outboard Model year 1998

Personal watercraft Model year 1999

Sterndriveinboard Model Year 2010

F Recreational spark-ignition engines andvehicles

mdash Model year 2006

G Other nonroad spark-ignition engines at orbelow 19 kW

H Other nonroad spark-ignition engines above19 kW

I Stationary compression-ignition engines mdash April 1 2006

J Stationary spark-ignition engines All engines with maximum engine power lt 19 kWNon-emergency engines with maximum engine power between 19

and 373 kW

July 1 2008

Non-emergency engines with maximum engine power gt 373 kW July 1 2007

Emergency engines with maximum engine power gt 19 kW January 1 2009

Decision flowchart for vehicles

1 Is it a motor vehiclesect851703 A vehicle which is self-propelled and capable of

transporting a person or persons or any material or any

permanently or temporarily affixed apparatus shall be deemed

a motor vehicle unless any one or more of the criteria set forth

below are met in which case the vehicle shall be deemed not a

motor vehicle

The vehicle cannot exceed a maximum speed of 25

miles per hour over level paved surfaces or

The vehicle lacks features customarily associated

with safe and practical street or highway use such

features including but not being limited to a reverse

gear (except in the case of motorcycles) a

differential or safety features required by state andor

federal law or

The vehicle exhibits features which render its use on

a street or highway unsafe impractical or highly

unlikely such features including but not being

limited to tracked road contact means an inordinate

size or features ordinarily associated with military

combat or tactical vehicles such as armor andor

weaponry

-If yes 40 CFR parts 85 and 86 apply

-If not see 2

2 Is it an off-highway motorcycle or snowmobilesect1051801 Off-highway motorcycle means a two-wheeled

vehicle with a nonroad engine and a seat (excluding marine

vessels and aircraft) (Note highway motorcycles are

regulated under 40 CFR part 86)

sect1051801 Snowmobile means a vehicle designed to operate

outdoors only over snow-covered ground with a maximum

width of 15 meters or less

-If yes part 1051 applies Note that sectsect1051605 and

1051610 allow for vehicles or engines to be certified

under part 86 or 1048 Note also that diesel-fueled

engines used with off-highway motorcycles or

snowmobiles may be certified under part 89 or 1039

under the provisions of sect10515

-If not see 3

3 Is it an offroad utility vehiclesect1051801 Offroad utility vehicle means a nonroad vehicle

that has four or more wheels seating for two or more persons

is designed for operation over rough terrain and has either a

rear payload capacity of 350 pounds or more or seating for six

or more passengers Vehicles intended primarily for

recreational purposes that are not capable of transporting six

passengers (such as dune buggies) are not offroad utility

vehicles (Note sect10511(a) specifies that some offroad utility

vehicles are required to meet the requirements that apply for

all-terrain vehicles)

-If yes see 4

-If not see 5

4 Is the offroad utility vehicle subject to part 1051sect10511(a)(4) Offroad utility vehicles with engines with

displacement less than or equal to 1000 cc maximum engine

power less than or equal to 30 kW and maximum vehicle

speed higher than 25 miles per hour Offroad utility vehicles

that are subject to this part are subject to the same

requirements as ATVs This means that any requirement that

applies to ATVs also applies to these offroad utility vehicles

without regard to whether the regulatory language mentions

offroad utility vehicles

engines used with offroad utility vehicles may be

certified under part 89 or 1039 under the provisions of

sect10515

-If not see 6

5 Is it an all-terrain vehiclesect1051801 All-terrain vehicle means a land-based or

amphibious nonroad vehicle that meets either of the following

criteria

(1) Vehicles designed to travel on four low pressure tires

having a seat designed to be straddled by the operator and

handlebars for steering controls and intended for use by a

single operator and no other passengers are all-terrain vehicles

(2) Other all-terrain vehicles have three or more wheels and

one or more seats are designed for operation over rough

terrain are intended primarily for transportation and have a

maximum vehicle speed of 25 miles per hour or higher Golf

carts generally do not meet these criteria since they are

generally not designed for operation over rough terrain

NOTE Amphibious vehicle means a vehicle with wheels or

tracks that is designed primarily for operation on land and

secondarily for operation in water

engines used with all-terrain vehicles may be certified

under part 89 or 1039 under the provisions of sect10515

-If not see 6

6 Does it have a spark-ignition enginesect1054801 Spark-ignition means relating to a gasoline-fueled

engine or any other type of engine with a spark plug (or other

sparking device) and with operating characteristics

significantly similar to the theoretical Otto combustion cycle

Spark-ignition engines usually use a throttle to regulate intake

air flow to control power during normal operation

-If yes see 7

-If not it is subject to standards for diesel engines

(marine locomotive or other land-based nonroad)

7 Is it a marine vesselsect1054801 Marine vessel has the meaning given in 1 USC

3 except that it does not include amphibious vehicles

[See 5] The definition in 1 USC 3 very broadly includes

every craft capable of being used as a means of transportation

on water

-If yes part 1045 applies

-If not the engine is subject to standards for Small SI or

Large SI engines depending on the maximum engine

power and total displacement

Radio Button Group 1 RBG1d

Radio Button Group 2 RBG2-1

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22a Max engine power

Radio Button Group 3-22b Off

22c Exempt from bond

22d NAIC

22e Policy number

22f State of issue

24aampb Location of storage

25 Describe exemption

Port code

CBP entry no

Entry date

Engine manufacturer Manufacture YANMAR Model 4TNV86-TKLA13Serial Number(s) See attached spreadsheet for engine detail

Month FEB

Year 2015

Radio Button Group 4 On engine

Engine build date explain

Vehicle or equipment manufacturer SEE ATTACHED Spreadsheet with all ENGINE DETAILS and SERIAL NUMBERS

Printed name Elena Walker

Date 02252015

Importer (required) THERMO KING PUERTO RICO13517 ZONA INDUSTRIAL 13ARECIBO PR 00612-3072 USA13EI REF 234007341713

Broker (required)

Owner (required)

FORM FDA 2877 (111) PSC Publishing Services (301) 443-6740PREVIOUS EDITION IS OBSOLETE PAGE 1 OF 2 PAGES EF

D DO NOT COMPLY WITH PERFORMANCE STANDARDS ARE HELD AND WILL REMAIN UNDER BOND AND WILL NOT BEINTRODUCED INTO COMMERCE UNTIL NOTIFICATION IS RECEIVED FROM FDA THAT PRODUCTS HAVE BEEN BROUGHTINTO COMPLIANCE IN ACCORDANCE WITH AN FDA APPROVED PETITION (See Form FDA 766)1 Approved Petition is attached 2 Petition Request is attached 3 Request will be submitted within 60 days

DEPARTMENT OF HEALTH AND HUMAN SERVICESFOOD AND DRUG ADMINISTRATION

Form Approved OMB No 0910-0025Expiration Date October 31 2013

DECLARATION FOR IMPORTEDELECTRONIC PRODUCTS SUBJECT TO

RADIATION CONTROL STANDARDS

INSTRUCTIONS

US CUSTOMS PORT OF ENTRY

NAME amp ADDRESS OF MANUFACTURING SITE COUNTRY OF ORIGIN

1 If submitting entries electronically through ACSABI hold FDA-2877 inentry file Do not submit to FDA unless requested

2 If submitting paper entry documents submit the following to FDAa 2 copies of Customs Entry Form (eg CF 3461 CF 3461 Alt

CF 7501 etc)b 1 copy of FDA 2877c Commercial Invoice(s) in English

ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY

NAME AND TITLE OF RESPONSIBLE PERSON

QUANTITY (ItemsContainers)

C DO NOT COMPLY WITH PERFORMANCE STANDARDS ARE BEING HELD UNDER A TEMPORARY IMPORT BOND WILL NOTBE INTRODUCED INTO COMMERCE WILL BE USED UNDER A RADIATION PROTECTION PLAN AND WILL BE DESTROYEDOR EXPORTED UNDER US CUSTOMS SUPERVISION WHEN THE FOLLOWING MISSION IS COMPLETE1 Research InvestigationsStudies or Training (attach Form FDA 766)

2 Trade ShowDemonstration List dates amp use restrictions

DECLARATION I WE DECLARE THAT THE PRODUCTS IDENTIFIED ABOVE (Mark X applicable statements fill in blanks amp sign)

B COMPLY WITH THE PERFORMANCE STANDARDS WHICH ARE APPLICABLE AT DATE OF MANUFACTURE AND THAT ACERTIFICATION LABEL OR TAG TO THIS EFFECT IS AFFIXED TO EACH PRODUCT COMPLIANCE DOCUMENTED IN1 Last annual report or ProductInitial report

2 Unknown manufacturer or report number State reason

NAME amp ADDRESS OF IMPORTER amp ULTIMATE CONSIGNEE (if not importer)

ACCESSION NUMBER of Report

Public reporting burden for this collection of information is estimated to average 02 hour per response including the time for reviewing instructions searchingexisting data sources gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burdenestimate or any other aspect of this collection of information including suggestions for reducing this burden to

Name of MANUFACTURER OF RECORD (Filed report with FDACDRH)

WARNING Any person who knowingly makes a false declaration may be fined not more than $10000 or imprisoned not more than 5 years or both pursuant to Title 18 USC 1001 Any person importing a non-compliant electronic product may also be subject to civil penalties of $1000 per violation up to a maximum $300000 for related violations pursuant to Title 21 USC 360pp

Department of Health and Human ServicesFood and Drug AdministrationOffice of Chief Information Officer1350 Piccard Drive Room 400Rockville MD 20850

An agency may not conduct or sponsor and a person is not required torespond to a collection of information unless it displays a currently validOMB control number

A ARE NOT SUBJECT TO RADIATION PERFORMANCE STANDARDS BECAUSE THEY1 Were manufactured prior to the effective date of any applicable standard Date of Manufacture 2 Are excluded by the applicability clause or definition in the standard or by FDA written guidance

Specify reason for exclusion 3 Are personal household goods of an individual entering the US or being returned to a US resident (Limit 3 of each product type)

4 Are property of a party residing outside the US and will be returned to the owner after repair or servicing

5 Are components or subassemblies to be used in manufacturing or as replacement parts (NOT APPLICABLE to diagnostic x-ray parts)

6 Are prototypes intended for on going product development by the importing firm are labeled FOR TESTEVALUATION ONLY and will be exported

destroyed or held for future testing (ie not distributed) (Quantities Limited - see reverse)

7 Are being reprocessed in accordance with PL 104-134 or other FDA guidance are labeled FOR EXPORT ONLY and will not be sold distributed

or transferred without FDA approval

MODEL NUMBER(S) amp BRAND NAME(S)

SIGNATURE OF IMPORTER OF RECORD

INSTRUCTIONS TO IMPORTERSBROKERS OF ELECTRONIC PRODUCTS

FORM FDA 2877 (111)

PURPOSE The Form FDA 2877 must be completed for electronic products subject to Radiation Control Standards (21 CFR 1010 and 1020-1050) prior to entry into the United States The local Food and Drug Administration (FDA) district office will review the declaration and notify the importeragent if the products may be released into US commerce or if they must be held under bond until exported destroyed or reconditioned Until the shipment is released it may be subject to redelivery for FDA examination

PAPER OR ELECTRONIC SUBMISSION Paper entries may be made by submitting the signed original FDA 2877 along with US Customs forms to the local FDA district office if electronic products are given a MAY PROCEED a signed copy of CF 3461 will be returned or if not given a MAY PROCEED a FDA Notice of Action will be issued For electronic entries follow US Customs Service ACSABI format and procedures supported by a signed copy of this form or similar letter Multiple entries of the same product and model families that are filed electronically may be supported by one form dated not more than 12 months previously

DECLARATION Select A B C or D and then select the appropriate number fill in requested information and sign For electronic entries AofC (affirmation of compliance) = RA RB RC or RD (eg Radiation Declaration A5 = RA5) Transmit model number using AofC code MDL and transmit brand name using FDA line level brand name field If RA3 or RA6 is selected you must transmit quantity (number of units) using the Quantity and Unit of Measure Pairs at the FDA line level

DECLARATION A Importers should be prepared to demonstrate compliance to or non-applicability of FDA standards regulations or guidance Components or sub-assemblies must be non-functioning Products being reprocessed must be exported by the importer without intermediate transfer of ownership For RA3 the quantity limit is 3 and for RA6 the limit = 50 units TV products microwave ovens and Class 1 laser products limit = 200 units CD-ROM and DVD (digital versatile disc) laser products see May 14 1997 notice toindustry issued by the Center for Devices and Radiological Health (CDRH)

DECLARATION B If declaration RB1 is selected provide the FDA Establishment Identifier (FEI) of the manufacturer who filed the radiation productabbreviated report to FDA CDRH Rockville Maryland To transmit the accession number of that report use AofC code ACC If the manufacturer cannot be determined or located the importer must be able to provide evidence showing a certification (certifi) label on each product and state reason returned to orig exporter or certifi label evidence The new AofC codes (RB1 RB2) for this declaration will not be activated until a process is made available to determine the FEI of the responsible firm Continue to use RAB in electronic transmission until the FEI query is available and industry is notified of its availability

DECLARATION C Noncompliant products may be imported only for research investigationsstudies demonstration or training They should be used only by trained personnel and under controlled conditions to avoid unnecessary radiation exposure Product(s) will be detained by the local FDA district office Since product(s) for which C Declarations are made will be under Temporary Import Bond (TIB) or equivalent ultimate disposition is limited to export or destruction under US Customs supervision when the purpose has been achieved or the length of time stated has expired For purposes other than demonstration the Form FDA 766 outlining protections must be approved by FDA prior to use The importerbroker must include with the FDA 766

1 A full description of the subject electronic product(s)2 The purpose for which the product(s) is being imported3 How the product(s) will be used4 Where the product(s) will be located5 The approximate length of time and dates the product(s) will be in this country

For product(s) being used for trade showsdemonstrations list the dates and use restrictions (Form FDA 766 is not required) A sign stating that the product does not comply with FDA performance standards must be displayed and viewable at all times during the use of product(s) All medical products cabinet x-ray or Class IIIb and IV lasers may NOT operate (turn on product(s)) at trade shows

DECLARATION D Noncompliant products must be brought into compliance with standards under FDA supervision and following a plan approved by FDA The plan documented on the Form FDA 766 must address technical requirements labeling and reporting Some plans may need approval by both the CDRH and the local FDA district office Use of this declaration is limited to occasional shipments ongoing reconditioning is considered manufacturing that is handled through other means Product(s) will be detained by the local FDA district office An FDA 766 must be filed indicating the procedure intended to bring the product into compliance This procedure will include a satisfactory corrective action plan andor a product report The FDA 766 must include all of the information requested under Declaration C The approximate length of time will be for the amount of time needed to bring product(s) into compliance Declaration D is also made for failure to provide reports failure to certify etc

If an importerbroker intends to import equipment into the United States for purposes of research investigation studies demonstrations or training but also wishes to retain the option of bringing the product into compliance with the performance standard check Declarations C and D on the FDA 2877 and insert the word or between the Affirmations Note The US Customs Service will treat this entry as a D Declaration for purposes of duty Such requests must be made on the FDA 766 include Items 1 2 and 3 under Declaration C a statement of the need to use the option C or D Declaration a statement of how the product(s) will be brought into compliance and the approximate length of time necessary to evaluate or demonstrate the product(s) and the time necessary to bring the product(s) into compliance (both actions must be accomplished within the period of time granted by FDA) For electronic entries select Declaration RD3

Ultimately product(s) must be brought into compliance with the applicable standard in accordance with a corrective action plan which has been approved by the FDA If the product(s) are not brought into compliance within the allotted time frame of the approved application and an extension is not requested of or granted by the FDA the local FDA district office shall refuse entry on the shipment and require the product(s) to be either exported or destroyed under US Customs supervision

If additional guidance is needed please contact your local FDA district office or consult the following FDA web pages wwwfdagov wwwfdagovorahierora_field_namestxt and httpwwwfdagovoracompliance_refrpm

[Ref 21 USC 360mm 21 CFR 1005 19 CFR 1290-1291] FDA CP 7382007007A

PAGE 2 OF 2 PAGESPREVIOUS EDITION IS OBSOLETE

PSC Graphics

FORM FDA 2877 (111)

PSC Publishing Services (301) 443-6740

PSC Publishing Services 3 0 1 4 4 3 6 7 4 0

PREVIOUS EDITION IS OBSOLETE

PAGE 1 OF 2 PAGES

EF

D DO NOT COMPLY WITH PERFORMANCE STANDARDS

ARE HELD AND WILL REMAIN UNDER BOND AND WILL NOT BE

INTRODUCED INTO COMMERCE UNTIL NOTIFICATION IS RECEIVED FROM FDA THAT PRODUCTS HAVE BEEN BROUGHT

INTO COMPLIANCE IN ACCORDANCE WITH AN FDA APPROVED PETITION

(See Form FDA 766)

1 Approved Petition is attached

2 Petition Request is attached

3 Request will be submitted within 60 days

DEPARTMENT OF HEALTH AND HUMAN SERVICES

FOOD AND DRUG ADMINISTRATION

Form Approved OMB No 0910-0025

Expiration Date October 31 2013

DECLARATION FOR IMPORTED

ELECTRONIC PRODUCTS SUBJECT TO


INSTRUCTIONS



1 If submitting entries electronically through ACSABI hold FDA-2877 in

1 If submitting entries electronically through A C S A B I hold F D A - 2877 in

entry file Do not submit to FDA unless requested

2 If submitting paper entry documents submit the following to FDA

a 2 copies of Customs Entry Form (eg CF 3461 CF 3461 Alt

CF 7501 etc)

b 1 copy of FDA 2877

c Commercial Invoice(s) in English

ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)

C DO NOT COMPLY WITH PERFORMANCE STANDARDS

ARE BEING HELD UNDER A TEMPORARY IMPORT BOND WILL NOT

BE INTRODUCED INTO COMMERCE WILL BE USED UNDER A RADIATION PROTECTION PLAN AND WILL BE DESTROYED

OR EXPORTED UNDER US CUSTOMS SUPERVISION WHEN THE FOLLOWING MISSION IS COMPLETE

1 Research InvestigationsStudies or Training (attach Form FDA 766)


DECLARATION I WE DECLARE THAT THE PRODUCTS IDENTIFIED ABOVE

(Mark X applicable statements fill in blanks amp sign)

B COMPLY WITH THE PERFORMANCE STANDARDS

WHICH ARE APPLICABLE AT DATE OF MANUFACTURE AND THAT A

CERTIFICATION LABEL OR TAG TO THIS EFFECT IS AFFIXED TO EACH PRODUCT COMPLIANCE DOCUMENTED IN

1 Last annual report or ProductInitial report


NAME amp ADDRESS OF IMPORTER amp ULTIMATE CONSIGNEE

(if not importer)


Public reporting burden for this collection of information

is estimated to average 02 hour per response including the time for reviewing instructions searching

existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information Send comments regarding this burden

estimate or any other aspect of this collection of information including suggestions for reducing this burden to

Name of MANUFACTURER OF RECORD

(Filed report with FDACDRH)


Department of Health and Human Services

Food and Drug Administration

Office of Chief Information Officer

1350 Piccard Drive Room 400

13 50 Piccard Drive Room 400

Rockville MD 20850

Rockville Maryland 2 0 8 5 0

An agency may not conduct or sponsor and a person is not required to

respond to a collection of information unless it displays a currently valid

OMB control number

A ARE NOT SUBJECT TO RADIATION PERFORMANCE STANDARDS BECAUSE THEY

1 Were manufactured prior to the effective date of any applicable standard Date of Manufacture

2 Are excluded by the applicability clause or definition in the standard or by FDA written guidance

Specify reason for exclusion

3 Are personal household goods of an individual entering the US or being returned to a US resident (Limit 3 of each product type)



5 Are components or subassemblies to be used in manufacturing or as replacement parts (NOT APPLICABLE to diagnostic x ray parts)






MODEL NUMBER OR NUMBERS amp BRAND NAME OR NAMES



FORM FDA 2877 (111)




DECLARATION A Importers should be prepared to demonstrate compliance to or non-applicability of FDA standards regulations or guidance Components or sub-assemblies must be non-functioning Products being reprocessed must be exported by the importer without intermediate transfer of ownership For RA3 the quantity limit is 3 and for RA6 the limit = 50 units TV products microwave ovens and Class 1 laser products limit = 200 units CD-ROM and DVD (digital versatile disc) laser products see May 14 1997 notice to industry issued by the Center for Devices and Radiological Health (CDRH)



1

A full description of the subject electronic product(s)

2

The purpose for which the product(s) is being imported

3

How the product(s) will be used

4

Where the product(s) will be located

5

The approximate length of time and dates the product(s) will be in this country







PAGE 2 OF 2 PAGES


txtPortofEntry

txtEntryNumber

dateEntryDate

txtNameManufactSite

txtNameImporter

txtProdDescr

txtQuantity

txtModelBrand

chkRadiationStandards 0

chkManuPrior 0

chkFDAGuidance 0

chkHouseGoods 0

chkForeignPropertyRepair 0

chkComponents 0

chkPrototypes 0

chkReprocessed 0

dateManufactureDate

txtReasonExclusion

chkComplyPerfStandards 0

chkAnnualReport 0

chkUnkManufacturer 0

txtUnkManufacturer

chkDoesNotComply 0

chkTradeShow 0

chkResearch 0

chkNotComply 0

chkApprovedPetition 0

chkPetitionReq 0

chkSubmitReq 0

txtResponsiblePerson

txtAccessionNum

txtManuOfRecord

txtDatesRestrictions

GPO SW 0015 ndash Supplier Assists for US Customs Page 1 of 5

Title Supplier Assists for US Customs Doc Number GPO SW 0015 Revision 1 Date 111815

Function Organization Author(s) Functional Owner Title

Global Procurement James Farr Senior Manager ndash Procurement Operations

Printed copies are valid only on the date of print | Company Confidential Print Date 6112018

1 PURPOSE

United States Customs requires that duties are assessed on the ldquoTransactional Valuerdquo of the imported product This transactional value includes more than the purchase price of the product For example if IR is assisting the supplier in the production of the component through the use of tooling material andor engineering the value of this assist must also be declared to US Customs The purpose of this standard work is to describe how IR will handle the declaration of assists for US Customs

2 OVERVIEW

A Scope Application

Assists apply only to non-US suppliers providing product to a US facility In this document the word ldquobuyerrdquo refers to Ingersoll Rand and the word ldquosellerrdquo refers to the supplier The supplier can be intercompany or an unrelated third party supplier Definition An Assist is any of the items listed below that the buyer of imported product provides directly or indirectly free of charge or at a reduced cost for use in production or sale of product for export to the United States

Materials components parts and similar items incorporated in the imported product

Tools dies molds and similar items used in producing the imported product

Product consumed in producing the imported product

Engineering development artwork design work and plans and sketches that are createddeveloped

outside the United States and are necessary for the production of the imported product Engineering

development will not be treated as an assist if the service or work is

Performed by a person domiciled within the United States

Performed while that person is acting as an employee or agent of the buyer of the imported

product

Incidental to other engineering development artwork design work or plans or sketches

undertaken within the United States

B Key Stakeholders

Stakeholder Impact

Supplier Must declare the assist on their invoice

PPM Insure assists are identified and declared

Trade Compliance Must insure process is being followed

C Roles amp Responsibilities

Role Responsibility

Buyer Ingersoll Rand or IR entity

Seller Non-US supplier

PPAP parts requisitioner

Insure a zero cost PO line is created that documents the Assist

PPM Communicate Assist requirements to supplier and inform Trade Compliance about the Assist

Supplier Include the Assist on the PPAP invoice per the wording in this standard work






D Timing

Process is executed every time there is an Assist

3 PROCESS GUIDANCE AND EXAMPLES

How to determine the value of the assist Materials amp components

if acquired from an unrelated seller the value will be the cost of acquisition

if produced by buyer or a related party to Ingersoll Rand (IR) the value is the cost of production

Plus in either case you must add in the cost of transportation to the place of production

Tools molds and dies



In either case if previously used by the buyer the original cost would be adjusted downward to reflect its

use

If leased by the buyer from an unrelated party the assist would be cost of lease

Plus in all cases you must add in the cost of transportation to the place of production

If the tool is repaired or modified the value will be the cost of the repair or modification only

Engineering

if in the public domain the cost of copies

if the assist was produced in the US and non-US countries the value added outside the US is the value

of the assist

if purchased or leased from an unrelated party to Ingersoll Rand (IR) the value of the assist is the cost of

purchase or lease

Examples of an Assist and determination of Assist value

IR pays a supplier to build tooling to support the production of an IR part for import to the US The cost of

producing the tooling plus the cost of transporting the tooling to the supplier is the assist value

IR sends casting patterns to a non-US supplier to make IR parts for import to the US The cost of

producing the tooling (adjusted for use if necessary) plus the cost of transporting the tooling to the

supplier is the assist value

IR moves tooling from any supplier to a non-US supplier to make parts for import to the US An assist

should be declared for the remaining value of the tooling and the cost of transporting the tooling

IR gives (or sells at a reduced cost) a special paint to a non-US supplier to paint an IR part for import to

the US The value of the paint provided (or the value of the reduced cost of the paint) plus the cost of

transportation is the value of the assist

IR gives (or sells at a reduced cost) a component to a non-US supplier for incorporation into an

assembled part that is imported to the US The value of the component (or the value of the reduced cost

of the component) plus the cost of transportation of the component is the value of the assist






What is NOT an Assist

IR sells a special paint at full price to a non-US supplier to paint an IR part for import to the US

IR sells a component at full price to a non-US supplier for incorporation into an assembled part that is

imported to the US

IR intercompany transfer of components imported to a plant in the US where the cost of tooling in include

in the transfer price of the components For example the Naroda India facilty ships bares to the

Campbellsville KY facility in the US Naroda includes the cost of tooling in their transfer price (via a

markup of their standard cost) No assist exists

A non-US IR factory provides tooling to a non-US supplier to allow them to produce components for the

non-US IR factory Subsequently a IR factory in the US decides to use the same supplier No assist

exists because the cost of the tooling was born by the non-US IR facility For example the Wujiang

China facility provides tooling to a Chinese supplier to use them to make components for Wujiang Later

Mocksville decides to utilize the same supplier No assist exists

What to do when we have an assist For tooling assists supplier must report the assist on the first PPAP invoice or the first shipment of parts off of the tooling This is done via the following steps

1 Requisition and subsequent purchase order for the PPAP parts includes a zero cost line documenting the

assist and itrsquos value (see example below)

2 PPM (or whoever creates the PPAP purchase order) contacts the supplier after they receive the purchase

order and communicates the proper method of documenting the assist on their invoice (see example

below)

3 PPM (or whoever creates the PPAP purchase order) must communicate to Trade Compliance that there

is an invoice with an assist BEFORE the shipment (IRImportComplianceircocom)

4 Supplier includes the assist on their invoice for the PPAP parts (see example below)

If supplier fails to document the assist on their first invoice the PPM (or whoever creates the PPAP purchase order) must obtain a corrected invoice from the supplier and provide it to Trade Compliance for Trade Compliance to submit a Post Summary Correction (PSC) to US Customs If the supplier needs to submit a second round of PPAP parts the second invoice will not include the Assist because the Assist was already declared on the first PPAP invoice For assists on materials and components incorporated into the imported product the PPM (or Materials Manager if there is not a PPM) must insure that the supplier reports the assist on each invoice of parts that are impacted by the assists






Examples of how an assist should look on a supplier invoice The following statement must appear on the supplierrsquos commercial invoice List specific tooling along with its value (calculated per above)






4 TOOLS FORMS TEMPLATES AND CHECKLISTS

Tool Access

5 REFERENCES

6 QUALITY AUDIT AND COMPLIANCE

Internal Audit will check for compliance to this process during internal audits of US locations The need to document assists is included in Standards of Internal Control document 191A paragraph 11

7 DEFINITIONS

Term or Acronym Definition

PPAP Production Part Approval Process ndash see IRPDP document PD-11400

PPM Plant Program Manager ndash a Procurement role who serves as Procurements liason with a manufacturing location

PSC Post Summary Correction The document that Trade Compliance will file with US Customs if the Supplier does not document the assist on the invoice

8 REVISION HISTORY

Use the revision format throughout all standard process documents in the sub-function (whether itrsquos 123 or AB C)

Revision No Date Description of Changes Name

1 111815 Initial Draft Jim Farr

Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd

Seamless Copper Tubing Worksheet

Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

image1png

image2png

TSCA Substance Control Act Declaration

RE CFR 12118 ndash 12127

EXPORTER__________________________________________

COUNTRY OF EXPORT ___________________________________

EXPORT INVOICE NO(s) __________________________________

__________________________________

I CERTIFY THAT ALL CHEMICAL SUBSTANCES IN THIS

SHIPMENT

FORMCHECKBOX COMPLY WITH ALL APPLICABLE RULES OR

ORDERS UNDER THE TOXIC SUBSTANCES CONTROL

ACT (TSCA) AND THAT I AM NOT OFFERING A

CHEMICAL SUBSTANCE FOR ENTRY INTO THE UNITED

STATES IN VIOLATION OF TSCA OR ANY APPLICABLE

RULE OR ORDER UNDER TSCA

FORMCHECKBOX ARE NOT SUBJECT TO THE TOXIC SUBSTANCES

CONTROL ACT (TSCA) PLEASE CONTACT THE

UNDERSIGNED IF FURTHER INFORMATION IS REQUIRED

Date_______________________________________

Signature_______________________________________

Name _______________________________________

Title_______________________________________

Email address_______________________________________

PART ________ Description_______

YES

NO

NOTE

Is ITEM a PART OF or COMPLETE-OPERATIONAL UNIT

Isdoes ITEM connect together any part of an air conditioning or heat pump (indoor or outdoor) to an evaporator unit

Is ITEM a LINE SET

Is ITEM a HOLLOW product or TUBE

Does part include SEAMLESS COPPER TUBING

Is SEAMLESS COPPER TUBING from MEXICO

Is SEAMLESS COPPER TUBING from CHINA

COUNTRY of MANUFACTURE of SEAMLESS COPPER TUBING

Is COPPER contained at least 9985 BY WEIGHT

Is COPPER and OTHER ELEMENTS contained AT LEAST 975 BY WEIGHT

What is the LENGTH (inches) of the SEAMLESS COPPER REFINED TUBING

What is the OUTSIDE DIAMETER (inches) of SEAMLESS REFINED COPPER TUBING

What is the ASTM

Associate Type Name Address1 Address2 Address3 Address4 Address5 Address6 Country City State Postal Number Type Number

SELLER 0 0 0 0 0 0 0 0 0 0

BUYER INGERSOLL RAND 0 0 0 USA 0 0 0 DUNS 13-515664000

SHIP_TO 0 0 DUNS

CONSIGNEE INGERSOLL RAND 0 0

CONSOLIDATOR 0 0 0

STUFFING_LOCATION 0 0

MANUFACTURER 0 0 0 0 0 0 0

Manufacturer Name Item Number (Required if nothing else but Manufacturer is filled in) Description (Required if nothing else but Manufacturer is filled in) HS Tariff (Required if nothing else but Manufacturer is filled in) Country of Origin (Required if nothing else but Manufacturer is filled in) PO Number (Required if nothing else but Manufacturer is filled in)

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SELLER 0 0 0 0 0 0 0 0 0 0


SHIP_TO 0 0 DUNS


CONSOLIDATOR 0 0 0



US IMPORTER SECURITY FILING SUBMISSION FORM

For all ocean bound cargo to the United States

Each Item Requires Manufacture Name amp Address Country of Origin Commodity HTSUS Number

Manufacturer Name amp Address

Definition Name and address of the entity that last manufactures assembles produces or grows the commodity or name and address of the party supplying the finished goods in the country from which the goods are leaving In the alternative the name and address of the manufacturer (or supplier) that is currently required by the import laws rules and regulations of the United States (ie entry procedures) may be provided (this is the information that is used to create the existing manufacture (MID) number for entry purposes)

Country of Origin Must be a valid 2 letter country code

Definition Country of manufacture production or growth of the article based upon the import laws rules and regulations of the United States

Commodity HTSUS Number Must be 6 - 10 digits periods are optional

Definition Dutystatistical reporting number under which the article is classified in the Harmonized Tariff Schedule of the United States (HTSUS) The HTSUS number must be provided to the six-digit level The HTSUS number may be provided up to the 10-digit level

Manufacturer Same as the Seller

Name 0 DUNS 0

Address1 0

Address2 0

Address3 0

City State Postal Code Country

Item - MUST BE IR CCN HTS CO PO Number Yes

No

copy 2008 Property of Expeditors International of Washington Inc and its subsidiaries Business Confidential and Proprietary Reproduction by written authorization only

ALABAMA

US IMPORTER SECURITY FILING SUBMISSION FORM CBP ALASKA

For all ocean bound cargo to the United States EIN AMERICAN SAMOA

SSN CFS ARIZONA

Summary of Shipment Information CY ARKANSAS

CALIFORNIA

Importer Ingersoll Rand Vendor Move Type

ISF Cut-Off Date Vessel Origin CY COLORADO

Vessel Sailing Date Voyage Destination CFS CONNECTICUT

HBL SCAC HBL MBL SCAC MBL DELAWARE

The House Bill consists of a SCAC Code (a four character code representing the AMS filer) and the House Bill of Lading Number (which DOES NOT exceed 12 characters) ISF requires the lowest manifested (AMS) bill of lading IF a HBL is issued the MBL is ONLY a reference in the ISF However if HBL is NOT applicable the Master Bill (also known as Regular Bill) MUST be used The SCAC Code is the four character code representing the vessel carrier The Master Bill of Lading Number (or Regular Bill) is twelve characters long and CAN NOT exceed 12 characters DISTRICT OF COLUMBIA

Data Elements Required for Importer Security Filing IDAHO

ILLINOIS

Seller Name amp Address or Dun amp Bradstreet Number (DUNS) Same as the Shipper INDIANA

Definition Name and address of the last known entity by whom the goods are sold or agreed to be sold If the goods are to be imported otherwise than in pursuance of a purchase the name and address of the owner of the goods must be provided IOWA

Name DUNS Yes KANSAS

No KENTUCKY

Address1 LOUISIANA

Address2 MAINE

Address3 MARSHALL ISLANDS

City State Postal Code Country MARYLAND

MASSACHUSETTS

Buyer Name amp Address or DUNS MICHIGAN

Definition Name and address of the last known entity to whom the goods are sold or agreed to be sold If the goods are to be imported otherwise than in pursuance of a purchase the name and address of the owner of the goods must be provided MINNESOTA

Name INGERSOLL RAND DUNS 13-515664000 MISSISSIPPI

MISSOURI

Address1 MONTANA

Address2 NEBRASKA

Address3 NEVADA

City State Postal Code Country USA NEW HAMPSHIRE

NEW JERSEY

Importer of Record Name or Number Same as the Buyer Yes NEW MEXICO

Definition Importer of record numberFTZ applicant identification number Internal Revenue Service (IRS) number Employer Identification Number (EIN) Social Security Number (SSN) or CBP assigned number of the entity liable for payment of all duties and responsible for meeting all statutory and regulatory requirements incurred as a result of importation For goods intended to be delivered to a Foreign Trade Zone (FTZ) the IRS number EIN SSN or CBP assigned number of the party filing the FTZ documentation with CBP must be provided NEW YORK

Name INGERSOLL RAND Number(if known) NORTH CAROLINA

NORTH DAKOTA

Consignee Name or Number Same as the Buyer Yes NORTHERN MARIANA ISLANDS

Definition Internal Revenue Service (IRS) number Employer Identification Number (EIN) Social Security Number (SSN) or CBP assigned number of the individual(s) or firm(s) in the United States on whose account the merchandise is shipped OHIO

Name INGERSOLL RAND Number(if known) OKLAHOMA

OREGON

Ship To Name amp Address or DUNS Same as the Buyer PALAU

Definition Name and address of the first deliver-to party scheduled to physically receive the goods after the goods have been released from customs custody PENNSYLVANIA

Name DUNS PUERTO RICO

RHODE ISLAND

Address1 SOUTH CAROLINA

Address2 SOUTH DAKOTA

Address3 TENNESSEE

City State Postal Code Country TEXAS

UTAH

Consolidator (Stuffer) Name amp Address or DUNS Same as the Seller VERMONT

Definition Name and address of the party who stuffed the container or arranged for the stuffing of the container For break bulk shipments the name and address of the party who made the goods ship ready or the party who arranged for the goods to be made ship ready must be provided VIRGIN ISLANDS

Name DUNS 0 VIRGINIA

WASHINGTON

Address1 WEST VIRGINIA

Address2 WISCONSIN

Address3 WYOMING

City State Postal Code Country AL

AK

Container Stuffing Location Name amp Address or DUNS Same as the Seller AS

Definition Name and address(es) of the physical location(s) where the goods were stuffed into the container For break bulk shipments the name and address(es) of the physical location(s) where the goods were made ship ready must be provided AZ

Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE

City State Postal Code Country DC

FM

copy 2010 Property of Expeditors International of Washington Inc and its subsidiaries Business Confidential and Proprietary Reproduction by written authorization only FL

GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Is part made of aluminum

Is part extruded aluminum

Is part a lsquopart ofrsquo and exported as a part lsquofinished goods kitrsquo unassembled as-is packaged together

Is part made of aluminum alloys containing metallic elements

Is part made of aluminum containing 99 aluminum alloy

If ldquoyesrdquo above What is the TOTAL MATERIAL BY WEIGHT

Is part made of aluminumaluminum alloy containing manganese

Is part made of aluminumaluminum alloy containing magnesium and silcon

Is the part produced by a method of casting

If ldquoyesrdquo What is The Aluminum Associations 4 digit casting identifier

Is part pure unwrought aluminum

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

See Commercial Invoice EXAMPLE below

Commercial Invoice

TEMPLATE1xls

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

COURIER SHIPMENTS

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

GPO SW 0015 -

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

TSCA Statement from

Supplierdoc

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

IRON PRODUCTS

STEEL PRODUCTS

BEARING Products

WORKSHEETdoc

Seamless COPPER

ALUMINUM Extrusion

WORKSHEETdocx

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

ISF Form for

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








PAGE 2 OF 2 PAGES


txtPortofEntry

txtEntryNumber

dateEntryDate

txtNameManufactSite

txtNameImporter

txtProdDescr

txtQuantity

txtModelBrand


chkManuPrior 0

chkFDAGuidance 0

chkHouseGoods 0


chkComponents 0

chkPrototypes 0

chkReprocessed 0

dateManufactureDate

txtReasonExclusion


chkAnnualReport 0


txtUnkManufacturer

chkDoesNotComply 0

chkTradeShow 0

chkResearch 0

chkNotComply 0


chkPetitionReq 0

chkSubmitReq 0


txtAccessionNum

txtManuOfRecord







1 PURPOSE


2 OVERVIEW

A Scope Application










product



B Key Stakeholders

Stakeholder Impact





Role Responsibility












D Timing











use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd


Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

image1png

image2png


RE CFR 12118 ndash 12127

EXPORTER__________________________________________



__________________________________


SHIPMENT










Date_______________________________________

Signature_______________________________________

Name _______________________________________

Title_______________________________________

Email address_______________________________________


YES

NO

NOTE















SELLER 0 0 0 0 0 0 0 0 0 0


SHIP_TO 0 0 DUNS


CONSOLIDATOR 0 0 0




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Address2 MAINE



MASSACHUSETTS




MISSOURI

Address1 MONTANA

Address2 NEBRASKA

Address3 NEVADA


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NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


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CA

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Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

COURIER SHIPMENTS

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

GPO SW 0015 -

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

TSCA Statement from

Supplierdoc

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

IRON PRODUCTS

STEEL PRODUCTS

BEARING Products

WORKSHEETdoc

Seamless COPPER

ALUMINUM Extrusion

WORKSHEETdocx

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

ISF Form for

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















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OMB control number

















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1


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RE CFR 12118 ndash 12127

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MISSOURI

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Address3 NEVADA


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NORTH DAKOTA




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RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


AK



Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

GPO SW 0015 -

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

TSCA Statement from

Supplierdoc

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

IRON PRODUCTS

STEEL PRODUCTS

BEARING Products

WORKSHEETdoc

Seamless COPPER

ALUMINUM Extrusion

WORKSHEETdocx

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

ISF Form for

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








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2 OVERVIEW

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Stakeholder Impact





Role Responsibility












D Timing











use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

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Lines CSV

Combined CSV

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Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

image1png

image2png


RE CFR 12118 ndash 12127

EXPORTER__________________________________________



__________________________________


SHIPMENT










Date_______________________________________

Signature_______________________________________

Name _______________________________________

Title_______________________________________

Email address_______________________________________


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Address2 MAINE



MASSACHUSETTS




MISSOURI

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Address2 NEBRASKA

Address3 NEVADA


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NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


AK



Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

TSCA Statement from

Supplierdoc

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

IRON PRODUCTS

STEEL PRODUCTS

BEARING Products

WORKSHEETdoc

Seamless COPPER

ALUMINUM Extrusion

WORKSHEETdocx

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

ISF Form for

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








PAGE 2 OF 2 PAGES


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2 OVERVIEW

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B Key Stakeholders

Stakeholder Impact





Role Responsibility












D Timing











use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd


Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

image1png

image2png


RE CFR 12118 ndash 12127

EXPORTER__________________________________________



__________________________________


SHIPMENT










Date_______________________________________

Signature_______________________________________

Name _______________________________________

Title_______________________________________

Email address_______________________________________


YES

NO

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MISSOURI

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Address2 NEBRASKA

Address3 NEVADA


NEW JERSEY




NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


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Name DUNS 0 AR

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Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

IRON PRODUCTS

STEEL PRODUCTS

BEARING Products

WORKSHEETdoc

Seamless COPPER

ALUMINUM Extrusion

WORKSHEETdocx

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

ISF Form for

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














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OMB control number

















FORM FDA 2877 (111)







1


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RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


AK



Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

ISF Form for

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








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Stakeholder Impact





Role Responsibility












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use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

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MBD0002C65Dvsd


Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

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image2png


RE CFR 12118 ndash 12127

EXPORTER__________________________________________



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Address2 MAINE



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MISSOURI

Address1 MONTANA

Address2 NEBRASKA

Address3 NEVADA


NEW JERSEY




NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


AK



Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

Document

IMP-USA-ENT-121

Rev 2 Original

JUNE 13 2018

Department

Supplier _________________

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

______________________________________________________________________

Part Number______________________________________________________________________

Housed______________

Plain Shaft______________

Linear________________________

Page 1 of 3

- wheel hub unit________________________

or other type_____________________

Page 2 of 3

_________________________________________________________________________

Sign _____________________________________________ Date ____ ____ ______

Contact email _______________________________

Phone __________________________

Page 3 of 3

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








PAGE 2 OF 2 PAGES


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txtEntryNumber

dateEntryDate

txtNameManufactSite

txtNameImporter

txtProdDescr

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2 OVERVIEW

A Scope Application










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B Key Stakeholders

Stakeholder Impact





Role Responsibility












D Timing











use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

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RE CFR 12118 ndash 12127

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Address2 NEBRASKA

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RHODE ISLAND



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WASHINGTON


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Address2 CT

Address3 DE


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HI

ID

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IA

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KY

LA

ME

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MA

MI

MN

MS

MO

MT

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NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

PART ___

YES

NOTE

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


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4


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Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd


Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

image1png

image2png


RE CFR 12118 ndash 12127

EXPORTER__________________________________________



__________________________________


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Title_______________________________________

Email address_______________________________________


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ILLINOIS




No KENTUCKY

Address1 LOUISIANA

Address2 MAINE



MASSACHUSETTS




MISSOURI

Address1 MONTANA

Address2 NEBRASKA

Address3 NEVADA


NEW JERSEY




NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


AK



Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








PAGE 2 OF 2 PAGES


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1 PURPOSE


2 OVERVIEW

A Scope Application










product



B Key Stakeholders

Stakeholder Impact





Role Responsibility












D Timing











use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd


Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

image1png

image2png


RE CFR 12118 ndash 12127

EXPORTER__________________________________________



__________________________________


SHIPMENT










Date_______________________________________

Signature_______________________________________

Name _______________________________________

Title_______________________________________

Email address_______________________________________


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NO

NOTE















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ALABAMA



SSN CFS ARIZONA


CALIFORNIA







ILLINOIS




No KENTUCKY

Address1 LOUISIANA

Address2 MAINE



MASSACHUSETTS




MISSOURI

Address1 MONTANA

Address2 NEBRASKA

Address3 NEVADA


NEW JERSEY




NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

Address3 WYOMING


AK



Name DUNS 0 AR

CA

Address1 CO

Address2 CT

Address3 DE


FM


GA

GU

HI

ID

IL

IN

IA

KS

KY

LA

ME

MH

MD

MA

MI

MN

MS

MO

MT

NE

NV

NH

NJ

NM

NY

NC

ND

MP

OH

OK

OR

PW

PA

PR

RI

SC

SD

TN

TX

UT

VT

VI

VA

WA

WV

WI

WY

(Please type)

75124 ndashM34d

CUSTOMS PORT CODE

_ _ _ _______ _Format XXX- 9 999999-9

and 373 kW

July 1 2008

motor vehicle

federal law or

weaponry

-If not see 2

-If not see 3

-If yes see 4

-If not see 5

sect10515

-If not see 6

criteria

-If not see 6

-If yes see 7

on water

1a Exempt from bond

1b NAIC

1c Policy number

1d State of issue

22d NAIC

22e Policy number

22f State of issue

Port code

CBP entry no

Entry date

Month FEB

Year 2015

Date 02252015

Broker (required)

Owner (required)







INSTRUCTIONS






ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


























FORM FDA 2877 (111)















PSC Graphics

FORM FDA 2877 (111)




PAGE 1 OF 2 PAGES

EF





(See Form FDA 766)











INSTRUCTIONS








CF 7501 etc)



ENTRY NUMBER

PRODUCT DESCRIPTION

DATE OF ENTRY


QUANTITY

(ItemsContainers)















(if not importer)














Rockville MD 20850




OMB control number

















FORM FDA 2877 (111)







1


2


3


4


5








PAGE 2 OF 2 PAGES


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txtEntryNumber

dateEntryDate

txtNameManufactSite

txtNameImporter

txtProdDescr

txtQuantity

txtModelBrand


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chkFDAGuidance 0

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chkPrototypes 0

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chkTradeShow 0

chkResearch 0

chkNotComply 0


chkPetitionReq 0

chkSubmitReq 0


txtAccessionNum

txtManuOfRecord







1 PURPOSE


2 OVERVIEW

A Scope Application










product



B Key Stakeholders

Stakeholder Impact





Role Responsibility












D Timing











use




Engineering



of the assist


purchase or lease























imported to the US















below)

















Tool Access

5 REFERENCES



7 DEFINITIONS





8 REVISION HISTORY




Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd


Supplier _________________


_________________________________________________________________________



Sign _____________________________________________ Date ____ ____ ______

Contact Email ___________________

Phone _____________________

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RE CFR 12118 ndash 12127

EXPORTER__________________________________________



__________________________________


SHIPMENT










Date_______________________________________

Signature_______________________________________

Name _______________________________________

Title_______________________________________

Email address_______________________________________


YES

NO

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No


ALABAMA



SSN CFS ARIZONA


CALIFORNIA







ILLINOIS




No KENTUCKY

Address1 LOUISIANA

Address2 MAINE



MASSACHUSETTS




MISSOURI

Address1 MONTANA

Address2 NEBRASKA

Address3 NEVADA


NEW JERSEY




NORTH DAKOTA




OREGON




RHODE ISLAND



Address3 TENNESSEE


UTAH




WASHINGTON


Address2 WISCONSIN

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AK



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PART ________ Description_______

	YES	NO	NOTE

Is ITEM a PART OF or COMPLETE-OPERATIONAL UNIT

Isdoes ITEM connect together any part of an air conditioning or heat pump (indoor or outdoor) to an evaporator unit

Is ITEM a LINE SET

Is ITEM a HOLLOW product or TUBE

Does part include SEAMLESS COPPER TUBING

Is SEAMLESS COPPER TUBING from MEXICO

Is SEAMLESS COPPER TUBING from CHINA

COUNTRY of MANUFACTURE of SEAMLESS COPPER TUBING

Is COPPER contained at least 9985 BY WEIGHT

Is COPPER and OTHER ELEMENTS contained AT LEAST 975 BY WEIGHT

What is the LENGTH (inches) of the SEAMLESS COPPER REFINED TUBING

What is the OUTSIDE DIAMETER (inches) of SEAMLESS REFINED COPPER TUBING

What is the ASTM

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SHIP_TO	0	0											DUNS

CONSIGNEE	INGERSOLL RAND											0		0

CONSOLIDATOR									0			0		0

STUFFING_LOCATION											0		0

MANUFACTURER	0	0		0		0							0			0		0

Manufacturer Name	Item Number (Required if nothing else but Manufacturer is filled in)	Description (Required if nothing else but Manufacturer is filled in)		HS Tariff (Required if nothing else but Manufacturer is filled in)		Country of Origin (Required if nothing else but Manufacturer is filled in)		PO Number (Required if nothing else but Manufacturer is filled in)

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	INVOICE CONTINUATION PAGE				Invoice Number

				Invoice Date

				PAGE NUMBER

	EXPORTER NAME LOGO Here

Line	Serial (if applicable)	DETAILED GOODS DESCRIPTION

	PO Number	Part Number	Written Item Description			QTY	COO	USD Unit Price	USD Line Item Total

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Documents

PROCEDURE Supplier Guide for U.S. Imports

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Invoice for CAN to USA

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MBD0002C65Dvsd

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MBD002315E0vsd

MBD0002C65Dvsd

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Invoice for CAN to USA

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Lines CSV

Combined CSV

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MBD0002C65Dvsd

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Invoice for CAN to USA

Invoice CONTINUATION Page

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Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd

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0000

Invoice for CAN to USA

Invoice CONTINUATION Page

Cover Sheet

Item Details

Associates CSV

Lines CSV

Combined CSV

MBD002315E0vsd

MBD0002C65Dvsd

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image1png

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0000

Invoice for CAN to USA

Invoice CONTINUATION Page

Cover Sheet

Item Details

Associates CSV