Custom Declaration Form
Name
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
1
How many family members traveling with you?
U.S. Address (Hotel/Destination)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Passport issued by
Country
Passport Number
Country of Residence
Flight # or Vessel Name
Countries visited on this trip prior to U.S. arrival
Primary purpose of this trip is
Business
Other
You are bringing
Fruits, vegetables, plants, seeds, food, insects
Meats, animals, animal/wildlife products
Disease agents, cell cultures, snails
Soil or have been on a farm/ranch/pasture
Have you been in close proximity of livestock
Yes
No
Do you carrying currency or monetary instruments over $10,000 U.S. or foreign equivalent?
Yes
No
Do you have commercial merchandise?
Yes
No
RESIDENTS: The total value of all goods, including commercial merchandise you have purchased or acquired abroad, and you are bringing to the U.S. is
VISITORS: The total value of all articles that will remainin the U.S., including commercial merchandise is:
Total Value
I, undersigned, agree with the following statements
All the information I provided by filling out this form is true and accurate.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
2
Signature
Submit
Should be Empty: