COST SUBMISSION BY

For the Period

through

CERTIFICATION

Name and Official Company Title

DEPARTMENT OF THE TREASURY 
United States Customs Service

19 U.S.C. 1511

COST SUBMISSION

OMB No. 1515-0085

Customs Form 247 (09/02)

This declaration of actual costs, inclusive of attached Exhibits A through D and required supporting schedules, is complete, accurate, and responsive to the instructions listed hereon to the best of my knowledge. Any omission resulting in the under payment of duties could result in the assessment of penalties under the provisions of Section 592, Tariff Act of 1930.

(mm/dd/yyyy)

(mm/dd/yyyy)

DEPARTMENT OF THE TREASURY
United States Customs Service Cost Submission
19 U S C 1 5 1 1 O M B Number 15 15-00 85 CERTIFICATION This declaration of actual costs, inclusive of attached Exhibits A. through D and required supporting schedules, is complete, accurate, and responsive to the instructions listed hereon to the best of my knowledge. Any omission resulting in the under payment of duties could result in the assessment of penalties under the provisions of Section 5 9 2, Tariff Act of 19 30. Customs Form 2 4 7 (09/02)

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