REPAIRER'S AFFIDAVIT I, _________________ declare that the articles herein specified are the articles which, in the condition in which they were exported from the United States, were received by us on _______, 199__ for the sole purpose of being repaired or altered; that only the repairs or alterations described below were performed by us; that the full cost (or when no charge is made) value of such repairs or alterations are correctly stated below; and that no substitution whatever has been made to replace any of the articles originally received by us from the owner or exporter. MODEL/SERIAL# REPAIRS COMPLETED DESCRIPTION TOTAL COST OF PARTS TOTAL COST OF LABOR                                         Attach a separate sheet if necessary Signature of Repairer ______________________ Company Name___________________________ Company Address _________________________ Dated _____________