I request that: (Mark only one code )
10
Bills, Refunds and 40
Bills and Notices 34
Checks and Notices
Notices of Liquidation
20
Checks for Refunds or 23
Bills and Checks
Drawback only
30
Bills Only 24
Notices of Liquidation only
be addressed to the undersigned in care of the agent whose Importer Number is shown below
whenever it appears as Reference Number on an Entry Summary (CBP 7501) for which I am (my
organization is) the Importer of Record.
Agent's Name _______________________________________ Agent's Number ________________
(Show hyphens)
DEPARTMENT OF
HOMELAND SECURITY
U.S. Customs and
Border Protection
SPECIAL
ADDRESS
NOTIFICATION
Note: A Report of Importer
Number (CBP 5106) must be
on
file
for each
Importer
Number appearing on
this
form.
Principal
Member of Firm
______________________________________________ ________
_____________of the Corp.
(Signature) (Date) (Title)
CBP Form 4811 (10/01)
My (organization's) Importer No.
(Show hyphens)