Sample US Customs Declaration Form - Immihelp

1 Customs Declaration19 CFR 1 , , , , , 14S8i 31 CFR 531 6 FORMAPPROVEDOil,lB NO. 1651-0009 Each arriving traveler or responsible family member must provide the followinginformation (only ONE wriften Declaration per family is required):1. FamilyNameFtlr.;t (Giorn) Middle2. Birdr date D^y Month Year3. Number of Family members traveling with you4. (a) Street Address (hotel name/destination)(b) City(c) State5. Passport issued by (country)6. Passport number7. Country of Residence8. Countries visited on thisrip prior to arrival9. Airline/Flight No. or Vessel Name10. The primary purpose of this trip is business: Yes NoI l. I am (We are) bringing(a) fruits, vegetables, plants, seeds, food, insects: Yes No(b) meats, animals, animaVwildlife products: Yes No(c) disease agents, cell cultures, snails: Yes No(d) soil or have been on a fann/rancVpasture: Yes have QV'e have) been in close proximity of(such as touching or handling) livestock: Yes NoI 3.

2 I am (We are) carrying currency or monetaryinstruments over $10,000 or foreign equivalent Yes No(see definition of monetary instrurnents on reverse) have (We have) commercial merchandise: Yes No(articles for sale, samples used for soliciting orders,or goods that are not considered perconal effects) - the total value of all goods, including commercialmerchandise I/we have purchased or acquired abroad, (including giftsfor someone else, but not items mailed to the ) and amlare bringingto the is: $Visitors - the total value of all articles that will remain in the commercial merchandise is: $Read the instructions on the back of this form . Soace is nrovided to list all theitems you must HAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OFTHI$ form AND HAVE MADE A TRUTHFUL form 60598 (01/04)For Official Use Onll' Customs and Border ProtectionWelcomes You to the United Customs and Border Protection is responsible for protecdng the UnitedStates against the illegal importation of prohibited items.

3 CBP officers have theauthority to question you and to examine you and your personal properry. Ifyou are one ofthe travelers selected for an examinarion, you will be treated in acourteous, professional, and dignified manner. CBP Supervisors and PassengerService Representatives are available to answer your questions. Comment cardsare available to compliment or provide Residents - declare all articles tiat you have acquired abroad and arebringing into the United (Non-Residents) - declare the value of all articles that will remainin the United all articles on this Declaration form and show the value in gifis, please indicate the retail - CBP officers will determine duty. residents are normally entitledto a duty-free exemption of $800 on items accompanying them. Visitors (non-residents) are normally entided to an exemption of $100. Dury witl be assessedat the current rate on the first $1,000 above the substances, obscene articles, and toxic substances aregenerally prohibited entfy.

4 Agriculture products are reefficted You, anil Vlhlccme to tbe IJniteil transportation of currency or monetary instruments, regardless of theamount, is legal. However, if you bring in to or take out of tle United Statesmore than $10,000 ( or foreign equivalent, or a combination of both), you arerequired by law to file a report on FinCEN 105 (formerly Customs form 4790)with Customs and Border Protection. Monetary instruments include , travelers check and bearer instruments such as personal or cashiers checksand stocks and bonds. If you have someone else carry the currency or monetaryinstrument for vou. vou must also file a reDort on FinCEN 105. Faiiure to file th! report or ir'il*" to report the tut;l amotrrft that carrying may leadto ttre seizure of all the currency or monetary instruments, and may subject you tocivil penalties and/or criminal prosecution.

5 SIGN ON THE OPPOSffE SIDE OFTHIS FORA4 AFTER YOU TIA\,'E READ THE IIVTPORTI{NT ,IAIIONABOVE AND MADE A TRUTHFI]L of Articles(List may contlnue on another CBP form 60598) ValUeTotalPAPERWORK REDUCTION ACf NOTICE: Th6 Paperuod( Reduclion Acl says w must tell you why we are mllecting thls intomation,t|o\ir lve will use it, and wheths you have to giv il to us. The information collecied on this fom is needed to c rry out the Customs ,Agticulhire, ad urency laws of the Unihd Stales. CBP requires the infornation on lfiis form to in6ure that travelers are mmplyingwih t s hs and io allow us to figure and mllect lhe fight amount of duty and tax. Your response is mandatory- An agencl may not$rduct s sponw, and a poFon is rct requiFd to 6pond to a coll clion of infomation, unless it displays a valid oMB 6ntml numberThe estimaH avemge burdon a$miated with lhis mllecton of infomation is 4 minutes per respondent or recod keeper depending onindividul cirdmstances.)}

6 Comm nts conceming the amumcy of $is burden estimate and suggesllons for rcducing this burden shouldbe directed to Custons and Bordsr Prdtection, Repons Clearanm offmr, lnfomation Seryices Branch, Washing'ton, Dc20229, and to the Offce ofManagemont and Budget, PapeMo* Reducdon Project ( ), Washington, DC 20503. THIS FORMI{AY NOT gE REPRODUCED WTHOUT APPROVAT FROI,I THE CBP FORMS MAI'IAGER' :2005 - 783-076/80026 CBP form 60598 (01/04)CBPtlse Only}