Statement Of United States Origin
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1Company Letterhead
Australia-United States Free Trade Agreement (AUSFTA)
STATEMENT OF UNITED STATES ORIGIN
I ______________________________ of
in the United States of America hereby
(name of company)
state that the goods supplied to
and described below are US
(Australian importer’s name)
originating goods as defined in Section 153YE of the Customs Act 1901 (and in paragraph 5.1
(b) of AUSFTA) as they are produced entirely in the US, or entirely in the US and Australia, and
contain non-originating materials.
The non-originating materials:
•
meet the requirements of the product specific rules of origin in the Schedule 1 Tariff
table in the Customs (Australia-US Free Trade Agreement) Regulations 2004 (and in
Annex 5A of AUSFTA), AND /OR
•
satisfy the de minimis requirements in Section 153YE of the Customs Act 1901 (and in
Article 5.2 of AUSFTA)
The applicable product specific rule of origin is:
Example only, replace with the actual rule for the product imported
8419.81
Either:
(a) a change to subheading 8419.81 from any other heading; or
(b) a change to subheading 8419.81 from subheading 8419.90, whether or not there is also
a change from any other heading, provided that there is a regional value content of not
less than 35 percent based on the build-up method or 45 percent based on the build-
down method.
Where there is more than one option, identify which rule has been satisfied
Description of Goods
Model/Product No. (if applicable)
Harmonized Tariff
Classification (6 digits)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
This statement applies to the goods above that are supplied on and from
(specify date in
DD/MM/YYYY format).
I
agree to maintain and present on request, documentation necessary
to support this statement. I further agree to inform, in writing, all persons to whom this
statement was given of any changes that could affect the accuracy or validity of this statement.
Signed by:
Position in Company:
Contact Details:
Full Name:
Date:
Note: The Australian importer should quote Preference Rule Type “PS” on the Import Declaration for the
goods described above.
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