DEPARTMENT OF THE TREASURY

U.S. CUSTOMS SERVICE

 

SUPPLEMENTAL DECLARATION

 

UNACCOMPANIED BAGGAGE

HOUSEHOLD EFFECTS

 

 

 

 

1.          OWNER OF HOUSEHOLD GOODS:                                                                                                                             

                (LAST NAME, FIRST AND MIDDLE)

 

2.            DATE OF BIRTH:                                                

 

3.             CITIZENSHIP:                                                   

4.          PASSPORT NO:  (COUNTRY AND NUMBER)

                                                                                               

 

5.            SOCIAL SECURITY NO:                    

 

6.             VISA NO:                                                             

7.          U.S. ADDRESS:                                                     

8.             EMPLOYER:                                                      

                                                                                               

                                                                                               

                                                                                               

                                                                                               

                                                                                               

 

9.             POSITION WITH COMPANY:                       

10.        FOREIGN ADDRESS:                                         

                                                                                               

                                                                                               

                                                                                               

                                                                                               

 

11.          LENGTH OF EMPLOYMENT:                       

                                                                                               

                                                                                               

 

12.        REASON FOR MOVING:                   

 

13.          NATURE OF BUSINESS:                 

                                                                                               

                                                                                               

 

14.        NAME/PHONE OF COMPANY OFFICIAL

 

                                                                                               

WHO CAN VERIFY ABOVE INFORMATION:

                                                                                               

 

15:        NAME/ADDRESS OF FREIGHT FORWARDER

 

                                                                                               

PACKERS AND SHIPPING AGENTS:

                                                                                               

 

16.        SHIPMENT ITINERARY:                                                                                                                                               

 

17.        CERTIFICATION:             A.  AUTHORIZED AGENT               B.  IMPORTER                    (CHECK ONE)

 

18.        SIGNATURE: