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["R"]
["Single Country Declaration"]
[]
["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)"]
[]
["Marks of identification Numbers","Description of Article & Quantity","Country of Origin","Date of Exportation"]
[]
[]
[null,"__________________________________________"]
[]
["Date :"]
[null,"__________________________________________ "]
["Name :"]
[null,"__________________________________________ "]
["Signature:"]
[null,"__________________________________________"]
["Title :"]
[null,"__________________________________________"]
["Company :"]
[null,"__________________________________________"]
["Address :"]

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