BSF249 - Least Developed Country Origin Verification Questionnaire - Preference Criteria E

PROTECTED B When Completed

Field A – Producer Information

• Company Name
• Company Address
• Contact Name
• Title
• Telephone No.
• E-mail Address
• Facsimile No.
• Company E-mail Address
• Fiscal Year End ()

Field B – Description of Good, or Representative Style, if Applicable Including HS Tariff Classification

• Please provide a copy of one commercial invoice for the selected style
• (Example 6107.11.10) HS Tariff Item

Field C – Shipping Details, Including Route to Canada

• Please provide a copy of the Bill of Lading for the selected style

Field D – If you have chosen a representative style, please provide all style numbers and descriptions that are covered by each representative style, as well as invoice references

• Style #
• Description
• Unit Price (US$)
• Invoice No.

Note: Attach a separate sheet of paper if you need more space

Field E – Description of Production Process

• Cutting
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Sewing
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Spinning
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Weaving
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Dyeing
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Printing
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Washing (Including Stonewashing)
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Knitting
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Assembly
  • Production Process (Yes/No)
  • Plant Name and Complete Address
• Other (Please describe)
  • Production Process (Yes/No)
  • Plant Name and Complete Address

Field F – Cost of production and other costs per piece

• Major Cost Category: Direct Labour Cost ( Note 1 )
  • Location Where Cost Was Incurred
  • Unit Cost (US$)
• Major Cost Category: Factory Overhead Cost ( Note 2 )
  • Location Where Cost Was Incurred
  • Unit Cost (US$)
• Major Cost Category: Other Production Costs ( Note 3 )
  • Location Where Cost Was Incurred
  • Unit Cost (US$)
• Total Costs of Production and Other Cost Components – carried forward to Costs of Production and other Costs per piece (B)

Notes:

1. Direct Labour Cost - The cost of the employees who work directly on the product and whose efforts can be identified with or specifically traced to a product or service. For example, direct labour includes the wages
   of cutters, sewers, and packers in a garment factory.
2. Factory Overhead Cost - It may include all production costs other than direct materials and direct labour. In a more specific sense, factory overhead cost represents the production costs that cannot be specifically identified with or traced directly to individual units of the finished product. For example, you may include such costs as indirect materials, supervision, repairs and maintenance, production assets depreciation, property taxes, insurance, utilities, janitorial services, security guards.
3. Other Production Costs - It may include any reasonable costs incurred during the normal manufacturing process, e.g., duties and taxes paid on imported materials and not refunded when the goods were exported. Any costs incurred subsequent to the goods leaving the factory, such as freight, loading, temporary storage, are excluded.

Field G – Reasonable Profit Per Piece

• Please provide an explanation on how you calculated the Reasonable Profit Component
• Reasonable Profit Component - carried forward to Reasonable Profit per piece (C)

Field H – Summary

1. Value of Materials per piece (US$)
   • LDC where good was assembled or Canada (A1)
   • All other countries (A2)
   • Aggregate (A1) + (A2) = (A3)
2. Costs of Production and other Costs per piece (US$)
   • Aggregate (A1) + (A2) = (A3)
3. Reasonable Profit per piece (US$)
   • Aggregate (A1) + (A2) = (A3)
4. Total Ex-Factory Price of the Good per piece (A3+B+C)
   • Aggregate (A1) + (A2) = (A3)
5. LDCT Qualifying Content (A1+B+C)
   • Aggregate (A1) + (A2) = (A3)
6. LDCT Qualifying Content Percentage (E/D) (example 35.25%)
   • Aggregate (A1) + (A2) = (A3)
     

Field I – Completion of the Questionnaire

Did a third party prepare this questionnaire? Yes/No

If yes, please provide the following information:

• Company Name
• Company Address
• Contact Name
• Title
• Telephone No.
• E-mail Address
• Facsimile No.
• Company E-mail Address

Field J – Certification

I certify that the information provided in response to this questionnaire is true and accurate. I agree to maintain, and present upon request, all records and documents necessary to support the representations made in response to this questionnaire.

• Title
• Telephone No.
• Facsimile No.
• E-mail address
• Name
• Signature
• Date ()

Field K – Value of Materials

• Item No.
• List of materials e.g.: Fabric, Accessories (Buttons, Rivets, Elastic, etc.)
• Unit Price (X) US $
• Quantity used per piece (Y)
• Cost per piece of garment (US$) (Z = X x Y)
  • LDC where goods are assembled or Canada (Z)
  • Cost incurred Elsewhere (Z)
• Supplier name
• Country of Origin
• Invoice no. Please attach the invoice
• Total Materials Cost Per Unit
• Total unit cost of materials - carried forward to Value of Materials per piece
  • Cost per piece of garment (US$) (Z = X x Y): (A)
  • LDC where goods are assembled or Canada (Z): A1
  • Cost incurred Elsewhere (Z): A2

Note: Please identify any materials supplied by the purchaser of the goods, even if at reduced cost or at no charge. If possible, please also provide the normal value of the materials provided by the purchaser of the goods.

Date modified:

2012-09-14