Approved OMB NO.

1651-0064
Exp. 03-31-2014
See back of form for Paperwork Reduction Act Notice.
1. TYPE OF ACTION (Mark all applicable)
DEPARTMENT OF HOMELAND SECURITY
Notification of Change of address*
U.S. Customs and Border Protection importer's number
Check here if you also want your address
Change of name* updated in the Fines, Penalties, and
IMPORTER ID INPUT RECORD Forfeitures Office
19 CFR 24.5
*NOTE--If a continuous bond is on file, a rider must accompany this change document.
2. IMPORTER NUMBER (Fill in one format):--

2A. I.R.S. Number 2B. Social Security Number

609-83-4621
Check here if requesting a CBP-assigned
2C. I have no IRS No. I have no I have not applied I am not a
number and indicate reason(s). Social Security No. for either number. U.S. resident
(Check all that apply.)

2D. CBP-Assigned Number

3. Importer Name
CYNTHIA TRAN
4. DIV/AKA/DBA 5. DIV/AKA/DBA Name
DIV AKA DBA

6. Type

Corporation Partnership Sole Proprietorship Individual U.S. Government State/Local Governments Foreign Governments

7. Importer Mailing Address (2 32-character lines maximum)

3290 Sawtelle Blvd Apt 103

8. City 9. State Code 10. ZIP
LOS ANGELES CA 90066
11. Country ISO Code (Non-U.S. Only)

12. Importer Physical Location Address (2 32-character lines maximum, see instructions)
3290 Sawtelle Blvd Apt 103

13. City 14. State Code 15. ZIP

LOS ANGELES CA 90066
16. Country ISO Code (Non-U.S. Only)

17a. Has importer ever been assigned a CBP Importer Number using the 17b. Has importer ever been assigned a CBP Importer Number using a name
same name as in Block 3? different from that in Block 3?
No Yes (List number(s) and/or name(s) in Block 17c.) No Yes (List number(s) and/or name(s) in Block 17c.)

17c. If ''Yes'' to 17a and/or 17b, list number(s) and/or name(s)

I CERTIFY: That the information presented herein is 18. Printed or Typed Name and Title 19. Telephone No. Including Area Code
correct; that if my Social Security Number is used it is
because I have no IRS Employer Number, that if my
CBP assigned number is used it is because I have CYNTHIA TRAN 3104096849
neither a Social Security Number nor an IRS Employer 20. Signature 21. Date
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 CBP. X 06/23/2016
22. Broker Use Only

Previous Editions are Obsolete CBP Form 5106 (05/13)

PAPERWORK REDUCTION ACT STATEMENT: An agency may not conduct BLOCK 9 - STATE
or sponsor an information collection and a person is not required to respond to For a U.S. mailing address, insert a valid 2-position alphabetic U.S. state
this information unless it displays a current valid OMB control number and an postal code (see list below). For a Canadian mailing address, insert a 2-
expiration date. The control number for this collection is 1651-0064. The character alphabetic code representing the province of the importer's mailing
estimated average time to complete this application is 15 minutes. If you have address (see list below).
any comments regarding the burden estimate you can write to U.S. Customs
and Border Protection, Office of Regulations and Rulings, 799 9th Street, NW., BLOCK 10 - ZIP CODE
Washington DC 20229. For a U.S. mailing address, insert a 5 or 9 digit numeric ZIP code as
established by the U.S. Postal Service. For a Canadian mailing address,
PRIVACY ACT STATEMENT: Pursuant to the requirements of Public Law insert a Canadian postal routing code. For a Mexican mailing address, leave
93-579 (Privacy Act of 1974, notice is hereby given that 19 CFR 24.5 blank. For all other foreign mailing addresses, a postal routing code may be
authorizes the disclosure of Social Security numbers (SSN) on the CBP Form inserted.
5106. The principal purpose for disclosure of the Social Security number is to BLOCK 11 -COUNTRY ISO CODE
assure maintenance of records that have a high degree of usefulness in For a U.S. mailing address, leave blank. For any foreign mailing address,
regulatory investigations or proceedings. The information collected may be including Canada and Mexico, insert a 2 character alphabetic International
provided to those officers and employees of the CBP and any constituent unit Standards Organization (ISO) code representing the country. Please Note:
of the Department of the Homeland Security who have a need for the records Valid ISO codes may be found in Annex B of the Harmonized Tariff Schedule
in the performance of their duties. The records may be referred to any of the United States; Customs Directive 099 5610-002, ''Standard Guidelines
department or agency of the federal government upon the request of the head for the Input of Names and Addresses into ACS Files"; or CBP Form 7501
of such department or agency. The authority to collect the SSN is 31 CFR Instructions".
103.25. The SSN will be used to identify the individuals conducting business
with the CBP. BLOCK 12 - SECOND IMPORTER ADDRESS
If the importer's place of business is the same as the mailing address, leave
BLOCK 1 - TYPE OF ACTION blank. If different from the mailing address, insert the importer's business
Notification of Importer's Number - Check this box if you are a first time address in this space. A second address representing the importer's place of
importer, using an importer number for the first time, or if you have not business is to be provided if the mailing address is a post office box or
engaged in CBP business within the last year. drawer.

Change of Name - Check this box if this importer number is on file but there is BLOCK 13 - CITY
a change in the name on file. Insert the city name for the importer's business address.

Change of Address - Check this box if this importer number is on file but there BLOCK 14 - STATE
is a change in the address on file. For a U.S. address, insert a 2 character alphabetic U.S. state postal code
(see list below). For a Canadian address, insert a 2 character alphabetic code
BLOCK 2 - IMPORTER representing the province of the importer's business address (see list below).
BLOCK 15 - ZIP CODE
2A -IRS Number - Complete this block if you are assigned an Internal For a U.S. business address, insert a 5 or 9 digit numeric ZIP code as
Revenue Service employer identification number.
established by the U.S. Postal Service. For a Canadian address, insert a
2B -Social Security Number - Complete this block if no Internal Revenue Canadian postal routing code. For a Mexican address, leave blank. For all
Service employer identification number has been assigned. The Social other foreign addresses, postal routing code may be inserted.
Security number should belong to the principal or owner of the
company or the individual who represents the importer of record. BLOCK 16 - COUNTRY ISO CODE
For a U.S. address, leave blank. For any foreign address, including Canada
2C -Requesting a CBP Assigned Number - Complete this block if no Internal and Mexico, insert a 2 character alphabetic ISO code representing the country.
Revenue Service employer identification number has been assigned, or
no Social Security number has been assigned. If this box is checked, all BLOCK 17 - PREVIOUSLY ASSIGNED CUSTOMS IMPORTER NUMBER
corresponding boxes in 2C must also be marked. PLEASE NOTE. A Indicate whether or not importer has previously been assigned a CBP
CBP Assigned Number is for CBP use only and does not replace a Importer Number under the same name or a different name. If "Yes" to either
Social Security number or Internal Revenue Service employer question, list name(s) and/or number(s) in Block 17c.
identification number. In general, a CBP Assigned Number will only be
issued to foreign businesses or individuals, provided no IRS or Social OFFICIAL UNITED STATES POSTAL SERVICE
Security number exists for the applicant. If Block 2C is completed, this TWO-LETTER STATE AND POSSESSION ABBREVIATIONS
form must be submitted in duplicate. CBP will issue an Assigned
Number and return a copy of the completed form with the Assigned AL Alabama MT Montana
Number to the requester. This identification number will be used for all AK Alaska NE Nebraska
future CBP transactions when an importer number is required. If an AZ Arizona NV Nevada
Internal Revenue Service employer identification number and/or a Social AR Arkansas NH New Hamsphire
Security number are obtained after an importer number has been AS American Samoa NJ New Jersey
assigned by CBP, the importer will continue to use the assigned number CA California NM New Mexico
unless otherwise instructed. CO Colorado NY New York
2D -CBP Assigned Number - Complete this block if you are assigned a CT Connecticut NC North Carolina
CBP Assigned Number but there is an Action change (Block 1). DE Delaware ND North Dakota
DC Distric of Columbia MP Northern Mariana Islands
BLOCK 3 - IMPORTER NAME FM Federated States of Micronesia OH Ohio
If the name is an individual, input the last name first, first name, and middle FL Florida OK Oklahoma
initial. Business names should be input first name first. GA Georgia OR Oregon
GU Guam PW Palau
BLOCK 4 - DIV/AKA/DBA HI Hawaii PA Pennsylvania
Complete this block if an importer is a division of another company (DIV), is ID Idaho PR Puerto Rico
also known under another name (AKA), or conducts business under another IL Illinios RI Rhode Island
name (DBA). IN Indiana SC South Carolina
IA Iowa SD South Dakota
BLOCK 5 - DIV/AKA/DBA NAME KS Kansas TN Tennessee
Complete this block only if Block 4 is used. KY Kentucky TX Texas
BLOCK 6 - TYPE OF COMPANY LA Louisiana UT Utah
Check applicable box. Please Note: Place an *X* after U.S. Gov't only for a ME Maine VT Vermont
U.S. federal government department, agency, bureau or office. All federal MH Marshall Islands VA Virginia
agencies are assigned I.R.S. numbers which should be used for any CBP MD Maryland VI Virgin Islands
transactions by that agency. MA Massachusetts WA Washington
MI Michigan WV West Virginia
BLOCK 7 - IMPORTER MAILING ADDRESS MN Minnesota WI Wisconsin
This block must always be completed. It may or may not be the importer's MS Mississippi WY Wyoming
business address. Insert a post office box number, or a street number MO Missouri
representing the first line of the importer's mailing address (up to 32
characters). For a U.S. or Canadian mailing address, additional mailing OFFICIAL TWO-LETTER CANADIAN PROVINCE CODES
address information may be inserted (up to 32 characters). If a P.O. box AB Alberta
number is given for the mailing address, a second address (physical location) NS Nova Scotia
BC British Columbia
must be provided in Block 12. ON Ontario
MB Manitoba PE Prince Edward Island
BLOCK 8 - CITY NB New Brunswick QC Quebec
Insert the city name of the importees mailing address. NL Newfoundland (Incl. Labrador) SK Saskatchewan
NT Northwest Territories YT Yukon Territory

CBP Form 5106 (05/13)