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Approved through 12/31/95. OMB NO. isis-olgi
See back of form for Paperwork Reduction Act Notice.

DEPARTMENT OF THE TREASURY

1. TYPE OF ACTION (mark all applicable)
Notification of importer's number

UNITED STATES CUSTOMS SERVICE

IMPORTER ID
INPUT RECORD

Check here it you also want your address updated in the Fines,
Penalties, and Forfeitures Office

Change of name*

FILL 2A OR 2B
19 CFR 24.5
2. IMPORTER NUMBER (Fill in one format):-

• NOTE--If a continuous bond is on file, a bond rider must accompany this change document.

2 B. Social Security Number

2A. I.R. S. Number

-

Check here if requesting a

2C.

Change of address

I have no IRS No.

Customs Assigned number and indicate reason (s). (Check all that apply)

2D. Customs-Assigned Number

I have no
Social Security No.

-

I have not applied for either number.

I am not a
U.S. resident.

RETURN TO :.
AWB REF #:

3 Importer Name

5. DIV/ AKA/ DBA Name

4. DIV AKA DBA
DIV

AKA

DBA

6. Type
Corporation

Partnership

Sole Proprietorship

Individual

Other

U.S. Government

7. Importer Mailing Address (2 32-character lines maximum)

9. State Code

8. City

10. ZIP

I 11. Country I SO Code (Non-U-S- Only)

12. Importer Physical Location Address (2 32-character lines maximum: see instructions)

13. City

ACCOUNT

14. State Code

-

-

15 . ZIP

16. Country ISO Code ( Non-U-S- Only)

17a. Has importer ever been assigned a Customs Importer Number using the same name as in Block 3 ? 17 b. Has importer ever been assigned a Customs Importer Number using a name different from that in Block 3?
No

Yes (List number(s) and or name(a) in Block 17 c-)

No

Yes (List number ) and or name(s) in Block I 7 c.)

17 c. If ''Yes' to 17a and/or 17 b, list number(s) and/or name(s)

NOTE: If the owner or ultimate consignee is a corporation this form must be signed by the president, vice president, secretary, or