I, _____________________________ (Name) declare that the articles listed below and covered by the invoice of entry to which this declaration relates are wholly the gross product or manufacture of a single foreign territory or country or insular possession of the U.S. of fabricated component which are in whole the product of U.S. as identified below. I declare that information set forth in this declaration is correct and true to the best of my information.

A _____________________________ (Country)

B _____________________________ (Country)

C _____________________________ (Country)

D _____________________________ (Country)