Form 3495 Application for Exportation of Articles under Special Bo

View Form 3495 Instructions

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

Form Approved OMB No. 1651-0004
Exp. 01-31-2014

APPLICATION FOR EXPORTATION OF ARTICLES UNDER SPECIAL BOND
19 CFR 10.38

TO CBP PORT DIRECTOR
1. TO: CBP Port Director (Address)

2. FROM: (Name and Address of Importer or Agent)

ATTACH COPY OF EXPORT INVOICE DESCRIBING ARTICLES TO BE EXPORTED
3. Name of Exporting Carrier

4. Date of Departure

7. Port of Entry

8. Entry Number

10. Date Articles Available for CBP Examination

11. Signature of Importer or Agent

5. Country of Origin

Date

6. No. of Export Packages
9. Date Bonded Period Expires
12. Date

(FOR CBP USE ONLY)

NOTICE TO IMPORTER TO DELIVER ARTICLES TO BE EXAMINED AND IDENTIFIED FOR EXPORTATION
Date

13. Place of CBP Examination

15. CBP PORT DIRECTOR

14. Date

BY:

REPORT OF EXAMINATION
16. The articles covered by this application have been examined and agree with the invoice in content and No. of export pkgs. and are approved for export.
17. No. of Export Packages

18. Date of Delivery for Exportation

19. Marks and Numbers on Export Packages

20. The articles covered by this application do not agree with the invoice in content or in number of packages as follows

21. SIGNATURE OF EXAMINING CBP OFFICER

22. DATE

REPORT OF EXPORTATION
23. Home of Exporting Conveyance (Vessel, Railroad, Airline and Flight Number)
24. Date of Departure

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information
collection and a person is not required to respond to this information unless it displays a current

25. Manifest No.

valid OMB control number and an expiration date. The control number for this collection is
1651-0004. The estimated average time to complete this application is 8 minutes. If you have any

26. SIGNATURE OF CBP OFFICER

comments regarding the burden estimate you can write to U.S. Customs and Border Protection,
Office of Regulations and Rulings, 799 9th Street, NW., Washington DC 20229.

(CBP officer must return one copy of this
form to port of origin upon exportation.)

(Previous Editions are Obsolete)

CBP Form 3495 (01/11)