Cbp Form 5106 - Us Customs And Border Protection Page 2
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1
2PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct
BLOCK 9 - STATE
or sponsor an information collection and a person is not required to respond to
For a U.S. mailing address, insert a valid 2-position alphabetic U.S. state
this information unless it displays a current valid OMB control number and an
postal code (see list below). For a Canadian mailing address, insert a 2-
expiration date. The control number for this collection is 1651-0064. The
character alphabetic code representing the province of the importer's mailing
estimated average time to complete this application is 15 minutes. If you have
address (see list below).
any comments regarding the burden estimate you can write to U.S. Customs
BLOCK 10 - ZIP CODE
and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW.,
For a U.S. mailing address, insert a 5 or 9 digit numeric ZIP code as
Washington DC 20229.
established by the U.S. Postal Service. For a Canadian mailing address,
insert a Canadian postal routing code. For a Mexican mailing address, leave
PRIVACY ACT STATEMENT: Pursuant to the requirements of Public Law
blank. For all other foreign mailing addresses, a postal routing code may be
93-579 (Privacy Act of 1974, notice is hereby given that 19 CFR 24.5
inserted.
authorizes the disclosure of Social Security numbers (SSN) on the CBP Form
5106. The principal purpose for disclosure of the Social Security number is to
BLOCK 11 -COUNTRY ISO CODE
assure maintenance of records that have a high degree of usefulness in
For a U.S. mailing address, leave blank. For any foreign mailing address,
regulatory investigations or proceedings. The information collected may be
including Canada and Mexico, insert a 2 character alphabetic International
provided to those officers and employees of the CBP and any constituent unit
Standards Organization (ISO) code representing the country. Please Note:
of the Department of the Homeland Security who have a need for the records
Valid ISO codes may be found in Annex B of the Harmonized Tariff Schedule
in the performance of their duties. The records may be referred to any
of the United States; Customs Directive 099 5610-002, ''Standard Guidelines
department or agency of the federal government upon the request of the head
for the Input of Names and Addresses into ACS Files"; or CBP Form 7501
of such department or agency. The authority to collect the SSN is 31 CFR
Instructions".
103.25. The SSN will be used to identify the individuals conducting business
BLOCK 12 - SECOND IMPORTER ADDRESS
with the CBP.
If the importer's place of business is the same as the mailing address, leave
blank. If different from the mailing address, insert the importer's business
BLOCK 1 - TYPE OF ACTION
address in this space. A second address representing the importer's place of
Notification of Importer's Number - Check this box if you are a first time
business is to be provided if the mailing address is a post office box or
importer, using an importer number for the first time, or if you have not
drawer.
engaged in CBP business within the last year.
BLOCK 13 - CITY
Change of Name - Check this box if this importer number is on file but there is
Insert the city name for the importer's business address.
a change in the name on file.
BLOCK 14 - STATE
Change of Address - Check this box if this importer number is on file but there
For a U.S. address, insert a 2 character alphabetic U.S. state postal code
is a change in the address on file.
(see list below). For a Canadian address, insert a 2 character alphabetic code
representing the province of the importer's business address (see list below).
BLOCK 2 - IMPORTER
BLOCK 15 - ZIP CODE
2A
-IRS Number - Complete this block if you are assigned an Internal
For a U.S. business address, insert a 5 or 9 digit numeric ZIP code as
Revenue Service employer identification number.
established by the U.S. Postal Service. For a Canadian address, insert a
2B -Social Security Number - Complete this block if no Internal Revenue
Canadian postal routing code. For a Mexican address, leave blank. For all
Service employer identification number has been assigned. The Social
other foreign addresses, postal routing code may be inserted.
Security number should belong to the principal or owner of the
company or the individual who represents the importer of record.
BLOCK 16 - COUNTRY ISO CODE
For a U.S. address, leave blank. For any foreign address, including Canada
2C -Requesting a CBP Assigned Number - Complete this block if no Internal
and Mexico, insert a 2 character alphabetic ISO code representing the country.
Revenue Service employer identification number has been assigned, or
no Social Security number has been assigned. If this box is checked, all
BLOCK 17 - PREVIOUSLY ASSIGNED CUSTOMS IMPORTER NUMBER
corresponding boxes in 2C must also be marked. PLEASE NOTE. A
Indicate whether or not importer has previously been assigned a CBP
CBP Assigned Number is for CBP use only and does not replace a
Importer Number under the same name or a different name. If "Yes" to either
Social Security number or Internal Revenue Service employer
question, list name(s) and/or number(s) in Block 17c.
identification number. In general, a CBP Assigned Number will only be
issued to foreign businesses or individuals, provided no IRS or Social
OFFICIAL UNITED STATES POSTAL SERVICE
Security number exists for the applicant. If Block 2C is completed, this
TWO-LETTER STATE AND POSSESSION ABBREVIATIONS
form must be submitted in duplicate. CBP will issue an Assigned
AL
Alabama
MT
Montana
Number and return a copy of the completed form with the Assigned
AK
Alaska
NE
Nebraska
Number to the requester. This identification number will be used for all
future CBP transactions when an importer number is required. If an
AZ
Arizona
NV
Nevada
Internal Revenue Service employer identification number and/or a Social
AR
Arkansas
NH
New Hamsphire
Security number are obtained after an importer number has been
AS
American Samoa
NJ
New Jersey
assigned by CBP, the importer will continue to use the assigned number
CA
California
NM
New Mexico
unless otherwise instructed.
CO
Colorado
NY
New York
CT
Connecticut
NC
North Carolina
2D
-CBP Assigned Number - Complete this block if you are assigned a
DE
Delaware
ND
North Dakota
CBP Assigned Number but there is an Action change (Block 1).
DC
Distric of Columbia
MP
Northern Mariana Islands
FM
Federated States of Micronesia
OH
Ohio
BLOCK 3 - IMPORTER NAME
FL
Florida
OK
Oklahoma
If the name is an individual, input the last name first, first name, and middle
GA
Georgia
OR
Oregon
initial. Business names should be input first name first.
GU
Guam
PW
Palau
BLOCK 4 - DIV/AKA/DBA
HI
Hawaii
PA
Pennsylvania
Complete this block if an importer is a division of another company (DIV), is
ID
Idaho
PR
Puerto Rico
also known under another name (AKA), or conducts business under another
IL
Illinios
RI
Rhode Island
name (DBA).
IN
Indiana
SC
South Carolina
IA
Iowa
SD
South Dakota
BLOCK 5 - DIV/AKA/DBA NAME
KS
Kansas
TN
Tennessee
Complete this block only if Block 4 is used.
KY
Kentucky
TX
Texas
LA
Louisiana
UT
Utah
BLOCK 6 - TYPE OF COMPANY
ME
Maine
VT
Vermont
Check applicable box. Please Note: Place an *X* after U.S. Gov't only for a
MH
Marshall Islands
VA
Virginia
U.S. federal government department, agency, bureau or office. All federal
MD
Maryland
VI
Virgin Islands
agencies are assigned I.R.S. numbers which should be used for any CBP
MA
Massachusetts
WA
Washington
transactions by that agency.
MI
Michigan
WV
West Virginia
BLOCK 7 - IMPORTER MAILING ADDRESS
MN
Minnesota
WI
Wisconsin
This block must always be completed. It may or may not be the importer's
MS
Mississippi
WY
Wyoming
business address. Insert a post office box number, or a street number
MO
Missouri
representing the first line of the importer's mailing address (up to 32
characters). For a U.S. or Canadian mailing address, additional mailing
OFFICIAL TWO-LETTER CANADIAN PROVINCE CODES
address information may be inserted (up to 32 characters). If a P.O. box
AB
Alberta
NS
Nova Scotia
number is given for the mailing address, a second address (physical location)
BC
British Columbia
ON
Ontario
must be provided in Block 12.
MB
Manitoba
PE
Prince Edward Island
NB
New Brunswick
BLOCK 8 - CITY
QC
Quebec
NL
Newfoundland (Incl. Labrador)
Insert the city name of the importees mailing address.
SK
Saskatchewan
NT
Northwest Territories
YT
Yukon Territory
CBP Form 5106 (05/13)
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