Cbp Form 5106 - Us Customs And Border Protection
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1
2Approved OMB NO. 1651-0064
Exp. 03-31-2014
See back of form for Paperwork Reduction Act Notice.
1. TYPE OF ACTION (Mark all applicable)
DEPARTMENT OF HOMELAND SECURITY
Notification of
Change of address*
U.S. Customs and Border Protection
importer's number
Check here if you also want your address
Change of name*
updated in the Fines, Penalties, and
IMPORTER ID INPUT RECORD
Forfeitures Office
19 CFR 24.5
*NOTE--If a continuous bond is on file, a rider must accompany this change document.
2. IMPORTER NUMBER (Fill in one format):--
2A. I.R.S. Number
2B. Social Security Number
Check here if requesting a CBP-assigned
I have no
I have not applied
I am not a
2C.
I have no IRS No.
number and indicate reason(s).
Social Security No.
for either number.
U.S. resident
(Check all that apply.)
2D. CBP-Assigned Number
3. Importer Name
4. DIV/AKA/DBA
5. DIV/AKA/DBA Name
DIV
AKA
DBA
6. Type
Corporation
Partnership
Sole Proprietorship
Individual
U.S. Government
State/Local Governments
Foreign Governments
7. Importer Mailing Address (2 32-character lines maximum)
8. City
9. State Code
10. ZIP
11. Country ISO Code (Non-U.S. Only)
12. Importer Physical Location Address (2 32-character lines maximum, see instructions)
13. City
14. State Code
15. ZIP
16. Country ISO Code (Non-U.S. Only)
17a. Has importer ever been assigned a CBP Importer Number using the
17b. Has importer ever been assigned a CBP Importer Number using a name
same name as in Block 3?
different from that in Block 3?
No
Yes (List number(s) and/or name(s) in Block 17c.)
No
Yes (List number(s) and/or name(s) in Block 17c.)
17c. If ''Yes'' to 17a and/or 17b, list number(s) and/or name(s)
18. Printed or Typed Name and Title
19. Telephone No. Including Area Code
I CERTIFY: That the information presented herein is
correct; that if my Social Security Number is used it is
because I have no IRS Employer Number, that if my
CBP assigned number is used it is because I have
neither a Social Security Number nor an IRS Employer
20. Signature
21. Date
Number, that if none of these numbers is used, it is
because I have none, and my signature constitutes a
X
request for assignment of a number by CBP.
22. Broker Use Only
Previous Editions are Obsolete
CBP Form 5106 (05/13)
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Parent category: Legal