DOMINICAN REPUBLIC TWO FOR ONE

EARNED IMPORT ALLOWANCE PROGRAM
TRANSACTION FORM

Type of Transaction:





For all transactions, please provide the following information about your company:


COMPANY NAME
IMPORTER OF RECORD NUMBER
CONTACT PERSON(S):


If you are requesting a deposit into an existing account, please also provide the following information:

ACCOUNT NUMBER:
DESCRIPTION OF QUALIFYING FABRIC:
DEPOSIT AMOUNT (in SMEs):
AFFIRMATION THAT QUALIFYING FABRIC IS INTENDED FOR APPAREL PRODUCTION IN THE DOMINICAN REPUBLIC:I hereby affirm that the qualifying fabric described above is intended for apparel production in the Dominican Republic.




LIST OF SUPPORTING DOCUMENTS CONTAINED IN ATTACHED FILES:

(only Adobe Acrobat and Microsoft Word files are accepted)

NOTE: Please be aware that the Earned Import Allowance Online System cannot accept files larger than 10MB. However, account holders may submit multiple requests for deposits for the same fabric purchase, but must indicate that the requests as "Part 1", "Part 2", etc. Should you have any questions, please contact OTEXA at 202-482-3400




I HEREBY AFFIRM THAT THE INFORMATION CONTAINED IN THIS TRANSACTION REQUEST IS ACCURATE. I UNDERSTAND THAT OTEXA MAY, AT ANY TIME, INDEPENDENTLY VERIFY THE INFORMATION THAT I HAVE SUBMITTED ABOVE. I ALSO UNDERSTAND THAT OTEXA MAY ESTABLISH AND IMPOSE PENALTIES FOR THE SUBMISSION OF FRAUDULENT INFORMATION UNDER THIS PROGRAM, OTHER THAN A CLAIM UNDER THE CUSTOMS LAWS OF THE UNITED STATES OR UNDER TITLE 18, UNITED STATES CODE.


Submitted by:


NAME OF REQUESTOR
DATE