Customs Form 5106 (031595) Importer Id Input Record printable pdf download

Customs Form 5106 (031595) Importer Id Input Record

Approved through 12/31/95. OMB NO. 1515-0191

See back of form for Paperwork Reduction Act Notice.

DEPARTMENT OF THE TREASURY

1. TYPE OF ACTION (Mark all applicable)

UNITED STATES CUSTOMS SERVICE

Notification of

Change of address*

importer's number

IMPORTER ID

Check here if you also want your

address updated in the Fines,

Change of name*

INPUT RECORD

Penalties, and Forfeitures Office

*NOTE--If a continuous bond is on file, a bond rider must accompany this change document.

19 CFR 24.5

2. IMPORTER NUMBER (Fill in one format):--

2A. I.R.S. Number

2B. Social Security Number

Check here if requesting a

I have no

I have not applied

I am not a

Customs-assigned number and

2C.

I have no IRS No.

Social Security No.

for either number.

U.S. resident.

indicate reason(s).(Check all that apply.)

2D. Customs-Assigned Number

3. Importer Name

4. DIV/AKA/DBA

5. DIV/AKA/DBA Name

DBA

DIV

AKA

6. Type

Corporation

Partnership

Sole Proprietorship

Individual

U.S. Government

Other

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 Customs Importer Number using the same name as in Block 3?

17b. Has importer ever been assigned a Customs Importer Number using a name different from that in Block 3?

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

Customs-assigned number is used it is because I have

20. Signature

21. Date

neither a Social Security Number nor an IRS Employer

Number; that if none of these numbers is used, it is

because I have none, and my signature constitutes a

request for assignment of a number by Customs.

22. Broker Use Only

See Back of Form for Privacy Act Statement.

Customs Form 5106 (031595)

Customs Form 5106 (031595) Importer Id Input Record

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