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