U.S. Customs Declaration

U.S. Customs and Border Protection

Customs Declaration FORM APPROVED

Each arriving traveler or responsible family member must provide the following information (only ONE written declaration per family is required):

1. Family Name:
First(Given): Middle

2. Birth date: Day: Month: Year

3. Number of Family members traveling with you:

4. (a)U.S. Street Address (hotel name/destination):
(b)City: (c)State

5. Passport issued by (country):

6. Passport number:

7. Country of Residence:

8. Countries visited on this trip prior to U.S. arrival:

9. Airline/Flight No. or Vessel Name:

10. The primary purpose of this trip is business: Yes No

11. I am (We are) bringing
(a) fruits, vegetables, plants seeds, food, insects: Yes No
(b) meats, animals, animal/wildlife products: Yes No
(c) disease agents, cell cultures, snails: Yes No
(d) soil or have been a farm/ranch/pasture: Yes No

12. I have (We have) been in close proximity of (such as touching or handling) livestock: Yes No

13. I am (We are) Carrying currency or monetary instruments over $10,000 U.S. or foreign equivalent: Yes No

14. I have (We have) commercial merchandise (articles for sale, samples used for soliciting orders, or goods that
are not considered personal effects)

15. 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 am/are 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. Space is provided to list all the items you must declare.

I HAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF THIS FORM AND HAVE MADE A TRUTHFUL DECLARATION.

Signature Date(day/month/year)

For Official Use Only

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