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FORM APPROVED OMB NO. 1515-0053

DEPARTMENT OF THE TREASURY

PAPERWORK REDUCTION ACT NOTICE:

The Paperwork Reduction Act of 1980 says we must tell you

UNITED STATES CUSTOMS SERVICE

why we are collecting this information, how we will use it, and whether you have to give it

to us.

We ask for the information to carry out the Customs Service laws of the United

States. We need it to ensure that importers are complying with these laws and to allow us to

figure, collect, or refund the right amount of duty and tax. Your response is mandatory.

DECLARATION FOR FREE ENTRY

The estimated average burden associated with this collection of information is 10 minutes per

OF UNACCOMPANIED ARTICLES

respondent or recordkeeper depending on individual circumstances.

Comments concerning the

accuracy of this burden estimate and suggestions for reducing this burden should be directed

to U.S. Customs Service, Paperwork Management Branch, Washington DC 20229. DO NOT send

completed form(s) to this office.

19 CFR 148.6, 148.52, 148.53, 148.77

PART I— TO BE COMPLETED BY ALL PERSONS SEEKING FREE ENTRY OF ARTICLES

(Please consult with the Customs official for additional information or

assistance. REMEMBER— All of your statements are subject to verification. False declarations or failure to declare articles could result in penalties.)

1. IMPORTER'S NAME (Last, first and middle)

2. IMPORTER'S DATE OF BIRTH

3. IMPORTER'S DATE OF ARRIVAL

4. IMPORTER'S U.S. ADDRESS

5. IMPORTER'S PORT OF ARRIVAL

6. NAME OF ARRIVING VESSEL/CARRIER AND FLIGHT/TRAIN

7. NAME(S) OF ACCOMPANYING HOUSEHOLD MEMBERS (wife, husband, minor children, etc.)

A. DATE

B. NAME OF VESSEL/CARRIER

C. FROM (Country)

D. B/L OR AWB OR I.T. NO.

8 .THE

ARTICLES

FOR

W HICH

FREE

ENTRY

CLAIMED

BELONG TO ME AND/OR MY

FAMILY AND W ERE IMPORTED

E. NUMBER AND KINDS OF CONTAINERS

F. MARKS AND NUMBERS

PART II— TO BE COMPLETED BY ALL PERSONS EXCEPT U.S. PERSONNEL AND EVACUEES

9. RESIDENCY ("X" appropriate box)

A. NAME OF COUNTRY

B. LENGTH OF TIME

Yr.

I declare that my place of residence abroad

was

Mo.

C. RESIDENCY STATUS UPON MY/OUR ARRIVAL ("X" One)

(1) Returning resident of the U.S.

(2) Nonresident:

a. Emigrating to the U.S.

b. Visiting the U.S.

10. STATEMENT(S) OF ELIGIBILITY FOR FREE ENTRY OF ARTICLES

I the undersigned further declare that ("X" all applicable items and submit packing list):

A. Applicable to RESIDENT AND NONRESIDENT

C. Applicable to NONRESIDENT ONLY

( 1 )All household effects acquired abroad for which free entry is sought were used

( 1 )All articles of apparel, personal adornment, toiletries and similar personal effects for

abroad for at least one year by me or my family in a household of which I or my

which free entry is sought were actually owned by me and in the possession of myself,

family was a resident member during such period of use, and are not intended for

or those members of my family who accompanied me, at the time of departure to the

any other person or for sale. (9804.00.05, HTSUSA)

United States and that they are appropriate and are intended for our personal use and

not for any other person nor for sale. (9804.00.20 HTSUSA)

( 2 )All instruments, implements, or tools of trade, occupation or employment, and all

professional books for which free entry is sought were taken abroad by me or for

( 2 )Any vehicles, trailers, bicycles or other means of conveyance being imported are for

my account or I am an emigrant who owned and used them abroad. (9804.00.10,

the transport of me and my family and such incidental carriage of articles as are

9804.00.15, HTSUSA)

appropriate to my personal use of the conveyance. (9804.00.35, HTSUSA)

B. Applicable to RESIDENT ONLY

All personal effects for which free entry is sought were taken abroad by me or for my

account. (9804.00.45, HTSUSA)

PART III— TO BE COMPLETED BY U.S. PERSONNEL AND EVACUEES ONLY

I, the undersigned, the owner, importer, or agent of the importer of the personal and household effects for which free entry is claimed, hereby certify that they were in direct personal possession of

the importer, or of a member of the importer's family residing with the importer, while abroad, and that they were imported into the United States because of the termination of assignment to

extended duty (as defined in section 148.74(d) of the Customs Regulations) at a post or station outside the United States and the Customs Territory of the United States, or because of

Government orders or instructions evacuating the importer to the United States; and that they are not imported for sale or for the account of any other person and that they do not include any

alcoholic beverages or cigars. Free entry for these effects is claimed under Subheading No. 9805.00.50, Harmonized Tariff Schedule of the United States.

1. DATE OF IMPORTER'S LAST DEPARTURE FROM THE U.S.

2. A COPY OF THE IMPORTER'S TRAVEL ORDERS IS ATTACHED AND THE ORDERS

W ERE ISSUED ON:

PART IV— TO BE COMPLETED BY ALL PERSONS SEEKING FREE ENTRY OF ARTICLES

(Certain articles may be subject to duty and/or other requirements and

must be specifically declared herein. Please check all applicable items and list them separately in item D on the reverse.)

A. For U.S. Personnel, Evacuees, Residents and Non-Residents

B. For Residents and Non-Residents ONLY

(7) Foreign household effects acquired

(8) Foreign household effects acquired

(1) Articles for the account

(2) Articles for sale or