**TRATADO DE LIBRE COMERCIO CHILE - ESTADOS UNIDOS**

**UNITED STATES - CHILE FREE TRADE AGREEMENT**

# CERTIFICADO DE ORIGEN

# CERTIFICATE OF ORIGIN

+---------------------------------+---+-------+-----+-----+----+----+
| **Nombre y dirección del        | * |       |     |     |    |    |
| Exportador:**                   | * |       |     |     |    |    |
|                                 | P |       |     |     |    |    |
| (Exporter Name and Address)     | e |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
| **Número de Identificación      | í |       |     |     |    |    |
| Tributaria (RUT):**             | o |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
| (Tax Identification Number)     | o |       |     |     |    |    |
|                                 | q |       |     |     |    |    |
|                                 | u |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | u |       |     |     |    |    |
|                                 | b |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | : |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | B |       |     |     |    |    |
|                                 | l |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | k |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | P |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | f |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | M |       |     |     |    |    |
|                                 | u |       |     |     |    |    |
|                                 | l |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | p |       |     |     |    |    |
|                                 | l |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | E |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | s |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | F |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | h |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | : |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | F |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | / |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | / |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | F |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | h |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | é |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | : |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | T |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | / |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | / |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
|                                 | : |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| **Nombre y dirección del        | * |       |     |     |    |    |
| Productor**:                    | * |       |     |     |    |    |
|                                 | N |       |     |     |    |    |
| (Producer Name and Address)     | o |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
| **Número de Identificación      | b |       |     |     |    |    |
| Tributaria (RUT):**             | r |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
| (Tax Identification Number)     | y |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | ó |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | I |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | p |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | : |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | I |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | p |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | N |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | A |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | s |       |     |     |    |    |
|                                 | s |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | N |       |     |     |    |    |
|                                 | ú |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | I |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | f |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | ó |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | T |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | b |       |     |     |    |    |
|                                 | u |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | R |       |     |     |    |    |
|                                 | U |       |     |     |    |    |
|                                 | T |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
|                                 | : |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 | * |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
|                                 | ( |       |     |     |    |    |
|                                 | T |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | x |       |     |     |    |    |
|                                 | I |       |     |     |    |    |
|                                 | d |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | f |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | c |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | N |       |     |     |    |    |
|                                 | u |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | b |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | r |       |     |     |    |    |
|                                 | ) |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| **Descripción del (los)         |   | Cla   | *   | *   | *  | ** |
| producto (s)**                  |   | sific | *Cr | *Pr | *V | Pa |
|                                 |   | ación | ite | odu | al | ís |
| (Description of Goods)          |   | A     | rio | cto | or | de |
|                                 |   | rance | tr  | r** | C  | Or |
|                                 |   | laria | ato |     | on | ig |
|                                 |   |       | de  | Pr  | te | en |
|                                 |   | HS    | P   | odu | ni | ** |
|                                 |   | T     | ref | cer | do |    |
|                                 |   | ariff | ere |     | Re | C  |
|                                 |   | Clas  | nci |     | gi | ou |
|                                 |   | sific | a** |     | on | nt |
|                                 |   | ation |     |     | al | ry |
|                                 |   |       | P   |     | ** | of |
|                                 |   |       | ref |     |    | Or |
|                                 |   |       | ere |     | Re | ig |
|                                 |   |       | nce |     | gi | in |
|                                 |   |       | Cri |     | on |    |
|                                 |   |       | ter |     | al |    |
|                                 |   |       | ion |     | V  |    |
|                                 |   |       |     |     | al |    |
|                                 |   |       |     |     | ue |    |
|                                 |   |       |     |     | C  |    |
|                                 |   |       |     |     | on |    |
|                                 |   |       |     |     | te |    |
|                                 |   |       |     |     | nt |    |
+---------------------------------+---+-------+-----+-----+----+----+
|                                 |   |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| Certificación de la Información |   |       |     |     |    |    |
| / Certification of Origin       |   |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
| Declaro bajo promesa de decir   |   |       |     |     |    |    |
| la verdad que / I certigy that: |   |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
| -   La información contenida en |   |       |     |     |    |    |
|     este documento es verdadera |   |       |     |     |    |    |
|     y exacta, y me hago         |   |       |     |     |    |    |
|     responsible de comprobar lo |   |       |     |     |    |    |
|     aquí declarado. Estoy       |   |       |     |     |    |    |
|     consciente que sere         |   |       |     |     |    |    |
|     responsible por cualquier   |   |       |     |     |    |    |
|     declaración falsa u         |   |       |     |     |    |    |
|     omission hecha en o         |   |       |     |     |    |    |
|     relacionada con el presente |   |       |     |     |    |    |
|     certificado. / The          |   |       |     |     |    |    |
|     information on this         |   |       |     |     |    |    |
|     document is true and        |   |       |     |     |    |    |
|     accurate and I assume the   |   |       |     |     |    |    |
|     responsibility for          |   |       |     |     |    |    |
|     providing such              |   |       |     |     |    |    |
|     representations. I          |   |       |     |     |    |    |
|     understand that I am liable |   |       |     |     |    |    |
|     for any false statements or |   |       |     |     |    |    |
|     material omissions made on  |   |       |     |     |    |    |
|     or in connection with this  |   |       |     |     |    |    |
|     document.                   |   |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
| ```{=html}                      |   |       |     |     |    |    |
| <!-- -->                        |   |       |     |     |    |    |
| ```                             |   |       |     |     |    |    |
| -   Me comprometo a conservar y |   |       |     |     |    |    |
|     presentar, en caso          |   |       |     |     |    |    |
|     requerido, los documentos   |   |       |     |     |    |    |
|     necesarios que respalden el |   |       |     |     |    |    |
|     contenido del presente      |   |       |     |     |    |    |
|     certificado, así como a     |   |       |     |     |    |    |
|     notificar por escrito a     |   |       |     |     |    |    |
|     todas las personas a        |   |       |     |     |    |    |
|     quienes se lo entregue, de  |   |       |     |     |    |    |
|     cualquier cambio que        |   |       |     |     |    |    |
|     pudiera afectar la          |   |       |     |     |    |    |
|     exactitud o validez del     |   |       |     |     |    |    |
|     mismo. / I agree to         |   |       |     |     |    |    |
|     maintain and present upon   |   |       |     |     |    |    |
|     request, documentation      |   |       |     |     |    |    |
|     necessary to support this   |   |       |     |     |    |    |
|     certificate, and to inform, |   |       |     |     |    |    |
|     in writing, all persons to  |   |       |     |     |    |    |
|     whom the certificate was    |   |       |     |     |    |    |
|     given of any changes that   |   |       |     |     |    |    |
|     could affect the accuracy   |   |       |     |     |    |    |
|     or validity of this         |   |       |     |     |    |    |
|     certificate.                |   |       |     |     |    |    |
|                                 |   |       |     |     |    |    |
| -   Las mercancías son          |   |       |     |     |    |    |
|     originarias del territorio  |   |       |     |     |    |    |
|     de los países y cumplen con |   |       |     |     |    |    |
|     los requisitos de origen    |   |       |     |     |    |    |
|     que les son aplicables      |   |       |     |     |    |    |
|     conforme al Tratado de      |   |       |     |     |    |    |
|     Libre Comercio entre la     |   |       |     |     |    |    |
|     República de Chile y los    |   |       |     |     |    |    |
|     Estados Unidos, no han sido |   |       |     |     |    |    |
|     objeto de procesamiento     |   |       |     |     |    |    |
|     ulterior o de cualquier     |   |       |     |     |    |    |
|     otra operación fuera de los |   |       |     |     |    |    |
|     territories de las Partes,  |   |       |     |     |    |    |
|     salvo en los casos          |   |       |     |     |    |    |
|     establecidos en el artículo |   |       |     |     |    |    |
|     4.11. / The goods           |   |       |     |     |    |    |
|     originated in the territory |   |       |     |     |    |    |
|     of the parties, and comply  |   |       |     |     |    |    |
|     with the origin             |   |       |     |     |    |    |
|     requirements specified for  |   |       |     |     |    |    |
|     those doods in the United   |   |       |     |     |    |    |
|     States-Chile Free Trade     |   |       |     |     |    |    |
|     Agreement, and unless       |   |       |     |     |    |    |
|     specifically exempted in    |   |       |     |     |    |    |
|     Article 4.11, There has     |   |       |     |     |    |    |
|     been no further production  |   |       |     |     |    |    |
|     or any other operation      |   |       |     |     |    |    |
|     outside the territories of  |   |       |     |     |    |    |
|     the Parties.                |   |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| Authorized Signature            | C |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | p |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | y |       |     |     |    |    |
|                                 | N |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | m |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| Name (Print or Type)            | T |       |     |     |    |    |
|                                 | i |       |     |     |    |    |
|                                 | t |       |     |     |    |    |
|                                 | l |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| Date (MM/DD/YY)                 | T |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | l |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | p |       |     |     |    |    |
|                                 | h |       |     |     |    |    |
|                                 | o |       |     |     |    |    |
|                                 | n |       |     |     |    |    |
|                                 | e |       |     |     |    |    |
|                                 | / |       |     |     |    |    |
|                                 | F |       |     |     |    |    |
|                                 | a |       |     |     |    |    |
|                                 | x |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+
| Field 12: Remarks               |   |       |     |     |    |    |
+---------------------------------+---+-------+-----+-----+----+----+

=