AUSFTA

USA – Sample Only

[On Company Letterhead]

Australia-United States Free Trade Agreement Declaration Statement of United States Origin
I _____________ of _____________ (Name of Company) hereby state that the goods supplied to
______________ (Australian Importer’s Name) on Invoice No. (s) ……………. and described below are of US
originating goods as defined in Section 153YC of the Customs Act of 1901.

Model(s)/Product Number(s)
__________________________________________________________________________________________
_

Description of Goods
__________________________________________________________________________________________
_

The above mentioned goods are:

PART A (Please tick one of the following)

( ) Wholly obtained or wholly produced from US originating materials of the USA or USA and Australia, as
defined in AUSFTA;
OR
( ) Entirely produced in the USA, or in the USA and Australia exclusively from origination
components/materials, as defined in the AUSFTA;
OR
( ) Produced from USA originating and non-originating materials, as defined in AUSFTA, and satisfy the
requirements of the product specific rule of origin relating to those goods, as detailed in Annex 4A or 5A of
AUSFTA and according to:
(If you have declared that this statement relates to the goods covered by this declaration, please provide further
details as set out below by the 4 sub-criteria)
[ ] The De Minimis Rule- The goods have 10% of the Customs Value or less of non-originating materials, as per
the AUSFTA Regulations.
OR
[ ] Change in Tariff classification Rule- The goods meet the Change of Classification Rule, and/or other Rules,
as per the AUSFTA Regulations.
AND/OR
[ ] Regional Value Content Rule – The goods meet the Regional Value Content Rule, stipulated at ___%
AND/OR
[ ] The goods meet any other requirements for the Specific Goods (Chapter 28-40)
OR
( ) Otherwise qualify as originating goods as prescribed, under the rules of origin in AUSFTA, and stipulated in
the Customs (Australia-US Free Trade Agreement) Regulations 2004.
(If you have declared that this statement relates to the goods covered by this declaration, please provide further
details on the criteria for claiming preference.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__
PART B

In addition, we declare that the goods have:

( ) Been transported directly to Australia from the USA as per AUSFTA requirements,
OR
( ) Been transported through another country or place but have not undergone any process of production in that
country or place, other than unloading, reloading or any other operation to preserve them in good condition
necessary for the goods to be transported to Australia.

We agree to maintain and present on request, documentation necessary to support this statement. We further
agree to inform, in writing, all persons to whom the statement was given of any changes that could affect the
accuracy or validity of this statement.

Full Name: (please print) ……………………………………… Position: …………………………

Signed: ………………………………………………………….... Dated: ……………………………