A link to the Portable Document Format (PDF) of this form is provided below. The content of the form is duplicated in HTML following the PDF link.
The purpose of this questionnaire is to request that you provide the Canada Border Services Agency (hereinafter referred to as "the CBSA"), with the information that you used to determine your eligibility for the North American Free Trade Agreement (hereinafter referred to as "the NAFTA"). This information is required to conduct a verification of origin of specified goods imported into Canada, pursuant to Article 506(1) of the NAFTA, for which claim for preferential tariff treatment was made on the basis that the goods originate in the NAFTA territory as a result of meeting a rule of origin under subsection 4(3) of the NAFTA Rules of Origin Regulations (hereinafter referred to as "the Regulations'), requiring that the goods were produced entirely in the territory of one or more of the Parties exclusively from originating materials.
Note 1: This questionnaire must be completed and returned by the date specified in the covering letter accompanying the questionnaire. Where CBSA does not receive the completed questionnaire within the specified time period, it may, subject to Paragraphs 16 through 18 of Article VI of the Uniform Regulations for the Interpretation, Application, and Administration of Chapter Three (National Treatment and Market Access for Goods) and Five (Customs Procedure) of the NAFTA deny preferential tariff treatment to the goods that are the subject of the verification of origin.
Note 2: This questionnaire will be used to verify the tariff treatment claimed by the importer, as outlined in Annex 302.2 of the NAFTA, paragraphs 4,5, or 6.
The CBSA may further verify the origin of the goods and/or determine the accuracy of any or all of the information provided in the completed questionnaire by sending a subsequent verification questionnaire or verification letter, and/or conducting a verification visit under Article 506(1) of the NAFTA.
Where materials used in the production of a good are obtained from suppliers in respect of which the exporter or producer claims that such materials are originating, it is incumbent upon that exporter or producer to substantiate the basis on which that claim was made. One way of substantiating the basis of the claim can be through written certifications from suppliers. As part of the overall verification process, the suppliers of those materials may be requested to complete a verification questionnaire and/or be the subject of a verification visit.
A failure to maintain, records relating to the origin of the goods that are the subject of the verification, for five years after the date on which the Certificate of Origin was signed or a denial of access to such records may, pursuant to Article V(4) of the Uniform Regulations of the NAFTA, result in a denial of preferential tariff treatment to the goods.
For additional information regarding the completion of this questionnaire, please refer to the NAFTA and the Regulations. Any further information and/or clarification may be obtained from the CBSA officer identified in the covering letter.
The Canada Border Services (CBSA), shall in accordance with Article 507 of the NAFTA and section 107 of the Customs Act, protect the confidentiality of all business information submitted and shall not, with the exception of the United States Bureau of Customs and Border Protection (CBP) of the United States, disclose such information to a third party without prior approval from your company. Pursuant to the Memorandum of Understanding Regarding the Exchange of NAFTA Related Information, the CBSA will share the results of this verification with the CBP.
The following definitions apply for purposes of this questionnaire.
- "Harmonized System (HS)"
- means the Harmonized Commodity Description and Coding System, including its General Rules of Interpretation, Section Notes and Chapter Notes as adopted and implemented by Canada under the Customs Tariff.
- "non-originating material"
- means a material that does not qualify as originating, under the Regulations.
- "originating material"
- means a material that qualifies as originating under the Regulations.
- means, with respect to
- (a) Canada, the territory to which its customs laws apply, including any areas beyond the territorial seas of Canada within which, in accordance with international law and its domestic law, Canada may exercise rights with respect to the seabed and subsoil and their natural resources,
- (b) Mexico,
- (i) the states of the Federation and the Federal District,
- (ii) the islands, including the reefs and keys, in adjacent seas,
- (iii) the islands of Guadalupe and Revillagigedo situated in the Pacific Ocean,
- (iv) the continental shelf and the submarine shelf of such islands, keys and reefs,
- (v) the waters of the territorial seas, in accordance with international law, and its interior maritime waters,
- (vi) the space located above the national territory, in accordance with international law, and
- (vii) any areas beyond the territorial seas of Mexico within which, in accordance with international law, including the United Nations Convention of the Law of the Sea, and its domestic law, Mexico may exercise rights with respect to the seabed and subsoil and their natural resources, and
- (c) the United States,
- (i) the customs territory of the United States , which includes the fifty states, the District of Columbia and Puerto Rico,
- (ii) the foreign trade zones located in the United States and Puerto Rico, and
- (iii) any areas beyond the territorial seas of the United States within which, in accordance with international law and its domestic law, the United States may exercise rights with respect to the seabed and subsoil and their natural resources.
Instructions on the completion of the questionnaire
Where there is insufficient space in this questionnaire to adequately respond to a request for information, attach additional pages appropriately numbered and cross-referenced.
Field 1: State the exporter's full legal name and address (including country).
Field 2: State the exporter's telephone number and facsimile number.
Field 3: Provide a detailed description of the goods being exported to Canada. Use a model or serial number where necessary to distinguish goods claimed as produced entirely in the territory of one or more of the Parties exclusively from originating materials from goods which are not so claimed. Please include product literature and promotional materials available for the good(s) under review.
Field 4: Provide the tariff classification of the goods. The tariff classification required is the CBSA Harmonized System classification to six digits.
Field 5: State the producer's full legal name and address, if different from the exporter.
Field 6: State the producer's telephone number and facsimile number, if different from the exporter.
Field 7: Where the goods identified in field 3 are produced entirely in the territory of one or more of the Parties exclusively from originating materials, list all materials used in the production process and identify the name and address of each supplier thereof. List all suppliers when there is more than one supplier for a particular material.
Field 8: Describe the production processes performed by you, in the order performed, and indicate where each process occurred.
Field 9: This field must be completed, signed and dated by the exporter or producer of the goods or by the supplier of a material used in the production of the goods, as the case may be.
Protected C when completed
Please print clearly
Complete fields 5 to 8 for all goods listed in field 3. Use copies of this page if necessary.
- 1. Exporter (Name and Address)
- 2. Tel. No. / Fax No.
- 3. Description of Goods
- 4. Tariff Classification
- 5. Producer (Name and Address), if different from exporter:
- 6. Tel. No. / Fax No
- 7. Materials and Suppliers:
- Suppliers (Names and Addresses)
- 8. Production Processes:
- 9. Certification – I certify that the information provided in response to this questionnaire is true and accurate and I assume the responsibility of proving such representations. I agree to maintain, and present upon request, all records and documentation necessary to support the representations made in response to this questionnaire. Use copies of this page if necessary
- Authorized Signature Company (print or type)
- Name (print or type)
- Title (print or type)
- Date (Y/M/D)
- Date modified: