A link to the Portable Document Format (PDF) of this form is provided below. The content of the form is duplicated in HTML following the PDF link.
This document must be presented to the CBSA, and the goods made available for examination and certification prior to destruction/exportation.
- 1. Applicant's name and address
- Business Number
- 2. Page (number) of (number)
- 3. Applicant's reference No.
- 4.(a) The goods described herein are being:
- destroyed détruites
- exported exportées
- 4.(b) Reason for destruction/exportation
- surplus or obsolete
- imported on a 1/60 basis
- duty deferral program
- temporary export
- prohibited goods, when permitted, in accordance with section 102(1) of the Customs Act
- 5. Weight
- 6. Currency used for declared value
- 7. If goods were previously accounted for at CBSA, state date of importation, CBSA office and accounting document transaction No.
- 8. Marks and numbers
- 9. Number and type of packages, complete description of goods (State serial, model, and part numbers, or other identifying marks.)
- 10. Quantity and unit of measure
- 11.Unit price
- 12. Value FOB place of lading
CBSA use only
- 13. Inspection comments
- 14. Scrap derived from the destruction of the goods described herein was:
- not disposed of at time of destruction
- 15. Place of destruction/exportation
- 16. The goods described herein appear to be:
- 17. Border services officer
- 18. Badge No. CBSA use only
- 19. Return certified copies to:
- 20. CBSA date stamp
Field No. 1. Enter the name, full address and Business Number of the applicant, e.g., importer of record, owner, exporter or consignor.
Field No. 2. Write "Page 1 of 1" if only one page is submitted. If three pages are submitted, write "Page 1 of 3" on the first page.
Field No. 3. Optional field. Enter the reference number, which the applicant can use to reference the merchandise in the company's record keeping system, e.g., purchase order, packing slip or invoice number.
Field No. 4. (a) - Indicate whether the goods are being destroyed or exported.
Field No. 4. (b) - Mark the appropriate box to indicate the reason for destruction or exportation. See field No.16 for more information.
Field No. 5. State the weight, both gross and net, including the unit of measurement. The gross weight is indicated on the waybill, bill of lading or similar transportation document. The net weight is found on the export invoice.
Field No. 6. Identify the currency used, e.g., Canadian dollars, U.S. dollars.
Field No. 7. If the goods were imported, state the date of importation, the import accounting transaction number, and the CBSA office where the accounting document was presented for each line in field 7.
Field No. 8. State the marks and numbers found on packages. For carloads, truckloads or containers, state the car, trailer or container number.
Field No. 9. State the number and type of packages. Provide a detailed description of the goods showing serial, model, part or catalogue numbers and any other identifying marks.
Field No. 10. State the quantity and unit of measure for each line.
Field No. 11. State the invoice unit price for each line.
Field No. 12. State the value for each line. This value includes the freight charges, handling, insurance or similar charges incurred to the place of exit from Canada, minus any discounts entered into prior to exportation, but will exclude these charges from the Canadian place of exit to the foreign destination. If the goods are shipped "no charge", show the selling price of the goods under normal conditions.
Fields 13-20, except field 19, are to be completed by the CBSA.
Field No. 13. Comment on discrepancies, condition of articles, scrap statement, method of destruction, etc.
Field No. 14. State the place where the goods were destroyed or from which they were exported.
Field No. 15. Indicate what happened to the scrap material. Comments could appear in field 13.
Field No. 16. Indicate the condition of goods before exportation or destruction. e.g., defective - refers to the state in which the goods were shipped, i.e., wrong yarn mixture, buttons missing; inferior - lesser quality than ordered; damaged - goods damaged in transit i.e., water, fire, smoke. When the CBSA believes that part of the goods have been used or are defective or damaged, comments should be made in field 13 specifying the quantity, description of the goods and the apparent use, defect or damage.
Field No. 17. Provide the CBSA officer's name.
Field No. 18. Provide the CBSA officer's badge number.
Field No. 19. Clearly print the complete address, including the postal code of the party who should receive the documents. (Completed by applicant).
Field No. 20. Provide the CBSA date-stamp.
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