Annual Report Questions

OMB Control No. 0625-0125

Expiration Date: 10/31/2027

<<Company Name>> Due by: <<Due Date>>, YYYY

Application No.:

ANNUAL REPORT QUESTIONS

For the Reporting Period of

<<Reporting Start Date>> – <<Reporting End Date>>

You must submit an annual report that updates the information under which the Certificate was granted (50 FR 1804-1812, January 11, 1985, codified in 15 C.F.R. 325.14). This form must be signed, dated, and returned as part of your submission. Failure to file an annual report in a timely manner could result in the revocation of the Certificate of Review.

Please identify your response by question numbers and identify the time period covered if

different from the reporting period given above.

1a. For the combined Products and Services listed under Export Trade in the Certificate,

provide in dollars for the Certificate holder:

a. total annual domestic sales, and

b. total annual export sales.

1b. For the combined Products and Services listed under Export Trade in the Certificate,

provide in dollars for each member separately:

a. total annual domestic sales, and

b. total annual export sales.

Note: If individual member sales figures are not available or are excessively burdensome to obtain, provide in dollar amounts the best possible estimate of aggregated member sales.

2. Provide the Certificate holder's annual financial statement for the most recent fiscal year.

If the date of the financial statement is more than six months earlier than the Certificate

anniversary date, also include the most recent quarterly financial statement. Neither

annual nor quarterly statements need be audited, but audited statements are preferred if

already prepared for the Certificate holder.

3. Have any firms or individuals listed as members in the Certificate ceased export operations, gone out of business or terminated their association with the Certificate holder? (Reminder: Adding new members to an existing Certificate requires filing a formal amendment.)

I certify that to the best of my knowledge and belief the information submitted in this report and the attachment is true and correct and fully responds to all annual report questions.

________________

TYPE OR PRINT NAME SIGNATURE (sign in ink) DATE

If you have any questions on the preparation of this annual report, please contact Amanda Reynolds at 202-482-5131.

Mail your annual report (an original and one copy) or email a signed PDF to:

Office of Trade and Economic Analysis

U.S. Department of Commerce

International Trade Administration/Trade Policy and Analysis

Rm. 21028

Washington, DC 20230

etca@trade.gov

Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0625-0125. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the International Trade Administration Paperwork Reduction Act Program: pra@trade.gov or to Katelynn Byers, ITA PRA Process Administrator: Katelynn.Byers@trade.gov.