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IMPORTER S BLANKET STATEMENT OF NON-REIMBURSEMENT OF ANTI-DUMPING DUTIES Date Importer Name/Address Manufacturer s Name/Address Anti-Dumping Case Numbers I hereby certify that this company corporation proprietorship or individual has not received nor entered into any agreement or understanding for the payment or for the reimbursement by the Manufacturer Producer Seller or Exporter of all or any part of the antidumping duties upon all shipments of Commodities Countries of Origin Which have been and/or will be imported by this company. Time Period From I further certify that the U*S* Customs and Border Protection will be notified if there is any payment or reimbursement of antidumping duties by the Manufacturer Producer Seller or Exporter to the importing company at any time in the future. Information regarding any such payment or reimbursement of antidumping duties will be sent immediately to the U*S* Customs and Border Protection* Failure to file this certificate prior to liquidation will result in the presumption of reimbursement and the assessment of double the antidumping duties. Signature of Company Officer Title of Officer Printed or typed name of above official Note This certificate must be signed by an officer of the importing company. Time Period From I further certify that the U*S* Customs and Border Protection will be notified if there is any payment or reimbursement of antidumping duties by the Manufacturer Producer Seller or Exporter to the importing company at any time in the future. Information regarding any such payment or reimbursement of antidumping duties will be sent immediately to the U*S* Customs and Border Protection* Failure to file this certificate prior to liquidation will result in the presumption of reimbursement and the assessment of double the antidumping duties. Information regarding any such payment or reimbursement of antidumping duties will be sent immediately to the U*S* Customs and Border Protection* Failure to file this certificate prior to liquidation will result in the presumption of reimbursement and the assessment of double the antidumping duties. Signature of Company Officer Title of Officer Printed or typed name of above official Note This certificate must be signed by an officer of the importing company. Time Period From I further certify that the U*S* Customs and Border Protection will be notified if there is any payment or reimbursement of antidumping duties by the Manufacturer Producer Seller or Exporter to the importing company at any time in the future. Information regarding any such payment or reimbursement of antidumping duties will be sent immediately to the U*S* Customs and Border Protection* Failure to file this certificate prior to liquidation will result in the presumption of reimbursement and the assessment of double the antidumping duties. Signature of Company Officer Title of Officer Printed or typed name of above official Note This certificate must be signed by an officer of the importing company. .

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