Please complete on company letterhead.
MANUFACTURER’S AFFIDAVIT & CERTIFICATE OF ORIGIN
1. Manufacturer Name / Address:
2. We hereby, affirm and declare that the products listed below are wholly the growth of the
country listed, or are substantially transformed by us, or certified to be substantially
transformed by others, through a process of manufacture (other than simple combining, repackaging, etc.) into its current FORM, FIT and FUNCTION as indicated in the parts listing below:
Part Number
Description
Country of Manufacture
Printed Name
Title
Date
Signature
Instructions for completing Manufacturer’s Affidavit:
The Manufacturer’s Affidavit is to be filled out by a party knowledgeable of the Manufacturing of the products,
or who can access the manufacturing records.