Sample U.s. Customs Declaration Form printable pdf download

Sample U.s. Customs Declaration Form

Customs Declaration

19 CFR 1 22.27, 148.12, 148.13, 148.110,148.111,

14S8i 31 CFR 531 6

FORMAPPROVED

Oil,lB NO. 1651-0009

Each arriving traveler or responsible family member must provide the following

information (only ONE wriften declaration per family is required):

1. FamilyName

Ftlr.;t (Giorn)

Middle

2. Birdr date

D^y

Month

Year

3. Number of Family members traveling with you

4. (a) U.S. Street Address (hotel name/destination)

(b) City

5. Passport issued by (country)

6. Passport number

7. Country of Residence

8. Countries visited on this

rip prior to U.S. arrival

9. Airline/Flight No. or Vessel Name

10. The primary purpose of this trip is business:

Yes

I l. I am (We are) bringing

(a) fruits, vegetables, plants, seeds, food, insects:

Yes

(b) meats, animals, animaVwildlife products:

Yes

(d) soil or have been on a fann/rancVpasture:

Yes

12.I have QV'e have) been in close proximity of

(such as touching or handling) livestock:

Yes

I 3. I am (We are) carrying currency or monetary

instruments over $10,000 U.S. or foreign equivalent

Yes

(see definition of monetary instrurnents on reverse)

14.I have (We have) commercial merchandise:

Yes

(articles for sale, samples used for soliciting orders,

or goods that are not considered perconal effects)

l5.Residents -

the total value of all goods, including commercial

merchandise I/we have purchased or acquired abroad, (including gifts

for someone else, but not items mailed to the U.S.) and amlare bringing

to the U.S. is:

Visitors -

the total value of all articles that will remain in the U.S..

including commercial merchandise is:

Read the instructions on the back of this form. Soace is nrovided to list all the

items you must declare.

I HAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF

THI$ FORM AND HAVE MADE A TRUTHFUL DECLARATION.

C B P F o r m 6 0 5 9 8 ( 0 1 / 0 4 )

For Official Use Onll'

SAMPLE

Sample U.s. Customs Declaration Form

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