MULTIPLE COUNTRY DECLARATION

I. (name), declare that the articles listed below and covered by the invoice or entry to which this declaration relates were exported from the country identified below on the dates listed and were subjected to assembling, manufacturing or processing operations in, and/or incorporate materials originating in, the foreign territory or country* or countries* or the U.S. or an insular possession of the U.S. identified below. I declare that the information set forth in this declaration is correct and true to the best of my information, knowledge, and belief

MULTIPLE COUNTRY DECLARATION