Approved through 12/31/95. OMB NO. isis-olgi
See back of form for Paperwork Reduction Act Notice.
DEPARTMENT OF THE TREASURY
1. TYPE OF ACTION (mark all applicable)
UNITED STATES CUSTOMS SERVICE
Check here it you also want your
address updated in the Fines,
Penalties, and Forfeitures Office
Change of name*
FILL 2A OR 2B
19 CFR 24.5
2. IMPORTER NUMBER (Fill in one format):-
• NOTE--If a continuous bond is on file, a bond rider must accompany this change document.
2 B. Social Security Number
2A. I.R. S. Number
Check here if requesting a
Change of address
I have no IRS No.
Customs Assigned number and
indicate reason (s). (Check all that apply)
2D. Customs-Assigned Number
I have no
Social Security No.
I have not applied
for either number.
I am not a
RETURN TO :.
AWB REF #:
3 Importer Name
5. DIV/ AKA/ DBA Name
4. DIV AKA DBA
7. Importer Mailing Address (2 32-character lines maximum)
9. State Code
I 11. Country I SO Code (Non-U-S- Only)
12. Importer Physical Location Address (2 32-character lines maximum: see instructions)
14. State Code
15 . ZIP
16. Country ISO Code ( Non-U-S- Only)
17a. Has importer ever been assigned a Customs Importer Number using the same name as in Block 3 ? 17 b. Has importer ever been assigned a Customs Importer Number using a name different from that in Block 3? No
Yes (List number(s) and or name(a) in Block 17 c-)
Yes (List number ) and or name(s) in Block I 7 c.)
17 c. If ''Yes' to 17a and/or 17 b, list number(s) and/or name(s)
NOTE: If the owner or ultimate consignee is a corporation this form must be signed by the president, vice president, secretary, or treasurer of the corporation, or by any employee or any agent of the corporation who holds a power of attorney and a certificate by the corporation that such employee or agent has or will have knowledge of the pertinent facts. I CERTIFY: That the information presented herein is 18. Printed or Typed Name and Title correct; that if my Social Security Number is used it is
because I have no IRS Employer Number; that if my
Customs-assigned number is used it is because I have
neither a Social Security Number nor an IRS Employer 20. Signature Number-, that if none of these numbers is used, it is
because I have none, and my signature constitutes a
request for assignment of a number by Customs.
1 9. Telephone No. including Area Code
22. Broker Use Only
CUSTOMS FORM 5106 (012293)
Paperwork Reduction Act Notice: We need this information to establish the importer-s name. address. and importer number. We , will use this information as basis for establishing bond coverage. release and entry of merchandise. liquidation, issuance of bills and refunds. and processing of drawback and FP &F actions. Your response is mandatory. .
Statement Required by 5 CFR 1320.21: The estimated average burden associated with this collection of information is 6 minutes per respondent or record keeper depending an individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs Service. Paperwork Management Branch Washington DC 202129. 00 NOT send completed form's) to this office. PRIVACY ACT STATEMENT: Pursuant to the requirements of Public Law 93-579 (Privacy Act of 1974. notice is hereby given that 19 CFR 24.5 authorizes the disclosure of Social Security numbers (SSN) on the Customs Form 5106. The principal purpose for disclosure of the Social Security number is to assure maintenance of records that have a high degree of usefulness in regulatory...
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