TREASURY DEPARTMENT

U.S. CUSTOMS SERVICE

 

SUPPLEMENTAL DECLARATION FOR

UNACCOMPANIED PERSONAL AND HOUSEHOLD EFFECTS

 

1.   OWNER OF HOUSEHOLD GOODS
      (Last name, first and middle)

2.   DATE OF BIRTH
3.   CITIZENSHIP
4.   PASSPORT (country and number)
5.   SOCIAL SECURITY NO.
6.   RESIDENT ALIEN NO.
7.   U.S. ADDRESS

 

8.   FOREIGN ADDRESS

 

9.   REASON FOR MOVING
10. EMPLOYER
11. POSITION WITH COMPANY
12. LENGTH OF EMPLOYMENT
13. NATURE OF BUSINESS
14. NAME AND TELEPHONE OF COMPANY
       WHO CAN VERIFY ABOVE INFORMATION
15. NAME AND ADDRESS OF FREIGHT FORWARDERS,
      PACKERS AND SHIPPING AGENTS

 

16. SHIPMENT ITINERARY
     (Specific place of loading and intermediate ports)

 

17. CERTIFICATE               A. Authorization Agent          B. Importer____(check one)
18. SIGNATURE