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SAMPLE B
Customs Declaration
customs use only
Department of the Treasury United States
Customs Service
Each arriving traveller or responsible family member must provide the following
information (only ONE written declaration per family is required):
1.Family Name ……………………………………………………………
2.First (Given) Name………………………………………………………
3.Middle Initial(s)………………………………………………………….
4.Birth Date (day/mo/yr)…………………………………………………...
5.Airline/Flight No. Or Vessel Name or Vehicle License No …………….
6.Number of Family Members travelling with You………………………
6. (a) Country or Citizenship………………………………………………..
7. (b) Country of Residence…………………………………………………
8. (a) U.S. Address (Street Number /Hotel/Mailing Address in U.S.)……….
9. (b) U. S. Address (City) ………………………………………………….
10. (c) U.S. Address (State) ………………………………………………….
11. Countries visited on this trip prior to U.S. arrival………………………..
12. The purpose of my (our) trip is or was Business.............Personal..... ..
(Check one or both boxes, if applicable)
13. I am (We are) bringing fruits, plants, metals, food,
soil, birds, snails, other live animals, wildlife products Yes No
farm products; or, have been on a farm or ranch
outside the U.S.
14. I am (We are) carrying currency or monetary
instruments over $ 10.000 U.S., or foreign Yes No
equivalent
15. I have (We have) commercial merchandise
U.S. or foreign (Check one box only) Yes No
16. The total value of all goods, including commercial
merchandise, I/we purchased or acquired abroad ………………
and am/are bringing to the U.S. is: (U.S. Dollars)
SIGN BELOW AFTER YOU READ NOTICE ON REVERSE
I have read the notice on the reverse and have made a truthful declaration.
……………….. ……………………….
Signature Date (day/month/year)
2.3.1 Translate the following sentences, words and phrases into English:
SAMPLE B Customs Declaration customs use only Department of the Treasury United States Customs Service Each arriving traveller or responsible family member must provide the following information (only ONE written declaration per family is required): 1.Family Name …………………………………………………………… 2.First (Given) Name……………………………………………………… 3.Middle Initial(s)…………………………………………………………. 4.Birth Date (day/mo/yr)…………………………………………………... 5.Airline/Flight No. Or Vessel Name or Vehicle License No ……………. 6.Number of Family Members travelling with You……………………… 6. (a) Country or Citizenship……………………………………………….. 7. (b) Country of Residence………………………………………………… 8. (a) U.S. Address (Street Number /Hotel/Mailing Address in U.S.)………. 9. (b) U. S. Address (City) …………………………………………………. 10. (c) U.S. Address (State) …………………………………………………. 11. Countries visited on this trip prior to U.S. arrival……………………….. 12. The purpose of my (our) trip is or was Business.............Personal..... .. (Check one or both boxes, if applicable) 13. I am (We are) bringing fruits, plants, metals, food, soil, birds, snails, other live animals, wildlife products Yes No farm products; or, have been on a farm or ranch outside the U.S. 14. I am (We are) carrying currency or monetary instruments over $ 10.000 U.S., or foreign Yes No equivalent 15. I have (We have) commercial merchandise U.S. or foreign (Check one box only) Yes No 16. The total value of all goods, including commercial merchandise, I/we purchased or acquired abroad ……………… and am/are bringing to the U.S. is: (U.S. Dollars) SIGN BELOW AFTER YOU READ NOTICE ON REVERSE I have read the notice on the reverse and have made a truthful declaration. ……………….. ………………………. Signature Date (day/month/year) 2.3.1 Translate the following sentences, words and phrases into English:
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