Approved OMB NO. 1651-0064

Approved OMB NO. 1651-0064 Exp. 03-31-2014 See back of form for Paperwork Reduction Act Notice. DEPARTMENT OF HOMELAND SECURITY U.S. Customs and Border Protection IMPORTER ID INPUT RECORD 19 CFR 24.5 1 TYPE OF ACTION (Mark allaPplahle) Nobficabon of 0 Change of address' importers number Change of name' rl Check here if you also want your address 1--1 updated in the Fines. Ponakies. and Forfeitures Office •NOTE--if a continuous bond is on file. a rider must accompany tees change document, 2. IMPORTER NUMBER (Fill in one format) -- 2k I.R.S. Number ri Check here if requesting a CBP-assigned Lj I have no IRS No. L-1 number and indicate reason(s) (Check ad that apply.) 28. Social Security Number I have no 0 I have not applied Social Security No. for either number. am not a U.S. resident 20. CBP-Assigned Number 3. Importer Name Fr o .....3 0 i c A A i 4. DIV/AKACEIA 0 ON 0 MCA 0 DBA 6. DIV/AiCNO8A Herne 6. Type K Corporation K Pannersho 9 Sole Proprietorship Individual K U S. Government riStateiLocal Governments 9 Foreign Governments 7. Mirk, lirtading Address (2 32-character lines maximum) CO '; -ErZAtn O1. s Avt- 8.c4CoLvvw)dr._ 11. Canby ISO Cole (Non.U.S. Only) 9 State Code 10 ZIP 0 - 2_ I 33 12. kriptifitit PbysiCal Location Address (2 32-character lines maximum. see instructions) 13. City 14 State Code 15 ZIP 16. Country ISO Code (NOn-M.S. Only) 178. Has Importer ever been assigned a CBP Ornerier Number using the same name as ii Block 37 El No 0 Yes (last ()umbels) &M/Or name(s) in Block 17c ) t7b. Has importer ever been assigned a CBP Importer Number using a name different from that in Block 3? 29 No 0 Yes (List number(S)andfor names) in Block 17c 17c. If "Yes- to 178 and/or 17b. list number(S) and/Or name(s) I CERTIFY: That the information presented herein is comet: that if my Social Security Number Is used it is because I have no IRS Employer Number, that if my CBP assigned number is used it is because I have neither a Social Security Number nor an IRS Employer Number, that it none of these numbers is used. it is because I have none, and my signature constitutes a request for assignment of a number by CBP. 22 Broker Use Only 18. Printed or Typed Name and Title \.)6',c '<\ , -D4reC.,Arr 19. Telephone No. lecke:ma Area Gotta II I 20 1 5 Previous Editions are Obsolete C8P Form 5106 (06/13) EFTA00300095