Exemption from Duty Form

EXEMPTION FROM DUTY FORM

Use this form to request an exemption from duty or tariff obligations for specific goods or services exchanged between the parties listed below. Completion and signature of this form constitute a binding representation that the facts and supporting documentation provided are true, accurate, and complete. Incomplete submissions may be rejected or delayed.

PARTIES

RECITALS

WHEREAS, Claimant Name: is the party requesting an exemption from duties assessed on certain goods or services described in this form; and

WHEREAS, Recipient Name: is the counterparty involved in the transaction and will rely on the exemption, if granted; and

WHEREAS, Claimant asserts that the goods or services described herein meet the statutory or regulatory criteria for exemption from duty as of Effective Date: , and seeks written confirmation of such exemption.

SCOPE OF WORK

Describe the transaction, the goods or services for which exemption is claimed, and the roles and responsibilities of each party. Include quantities, Harmonized System (HS) codes where applicable, and any processing or transformation to be performed.

DESCRIPTION OF GOODS / SERVICES

Provide an itemized description. Include quantity, unit value, total declared value, origin, and any identifying marks or model numbers.

LEGAL BASIS FOR EXEMPTION

State the statutory, regulatory, or treaty provision that supports the exemption claim and summarize how the facts satisfy the applicable criteria.

CUSTOMS / SHIPPING INFORMATION

PAYMENT TERMS

If duties would otherwise be payable, indicate the payment arrangement between the parties and any amounts that will be held in escrow or otherwise subject to adjustment pending resolution of the exemption claim.

TERM AND TERMINATION

This exemption request and any related obligations described in this form shall commence on Start Date: and shall continue until End Date: , unless earlier terminated in accordance with the notice provisions below.

Either party may terminate this agreement for material breach that remains uncured after the notice period specified above. Termination shall not relieve either party of obligations accrued prior to termination.

CONFIDENTIALITY

Each party agrees that confidential information disclosed in connection with this exemption request will be held in strict confidence and used solely for the purposes of evaluating and implementing the exemption. Confidential information does not include information that is or becomes publicly available through no breach of this form, or information rightfully received from a third party without restriction.

CERTIFICATION

The undersigned certifies, under penalty of law, that the information provided herein is true and complete to the best of their knowledge, that all supporting documentation furnished with this form is accurate, and that the claimed exemption is consistent with the stated legal basis and present facts. The undersigned acknowledges that knowingly providing false information may subject the signatory to applicable penalties, including fines and other enforcement measures.

GOVERNING LAW

This form and any resulting agreement between the parties shall be governed by and construed in accordance with the laws of the jurisdiction specified below, without regard to conflict-of-law principles.

ENTIRE AGREEMENT

This form, together with any attachments and supporting documentation expressly incorporated by reference, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior oral or written agreements, understandings, or communications relating thereto. No amendment or modification of this form shall be effective unless in writing and signed by both parties.

ADDITIONAL REPRESENTATIONS

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