Sample U.S. Customs Declaration Form - 6059B





FRONT

Each arriving traveler or responsible family member must provide the following information (only ONE written declaration per family is required):

U.S. Customs and
Border Protection
Customs Declaration
19 CFR 122.27, 148.12, 148.13, 148.110,148.111, 1498; 31 CFR 5316
FORM APPROVED
OMB NO. 1651-0009

Each arriving traveler or responsible family member must provide the following information (only ONE written declaration per family is required):
1. Print your last (family) name. Print your first (given) name. Print the first letter of your middle name.

2. Print your date of birth in the appropriate day/month/year boxes.

3. Print the number of family members traveling with you (do not include yourself).

4. Print your current street address in the United States. If you are staying at a hotel, include the hotel's name and street address. Print the city and the state in the appropriate boxes.

5. Print the name of the country that issued your passport.

6. Print your passport number.

7. Print the name of the country where you currently live.

8. Print the name of the country(ies) that you visited on your trip prior to arriving to the United States.

9. If traveling by airline, print the airline's name and flight number. If traveling by vessel (ship), print the vessel's name.

10. Mark an X in the Yes or No box. Are you traveling on a business (work-related) trip?

11. Mark an X in the Yes or No box. Are you bringing with you:
  1. fruits, plants, food, or insects?
  2. meats, animals, or animal/wildlife products?
  3. disease agents, cell cultures, or snails?
  4. soil or have you visited a farm/ranch/pasture outside the United States?
12. Mark an X in the Yes or No box. Have you or any family members traveling with you been in close proximity of (such as touching or handling) livestock outside the United States?

13. Read definition of monetary instruments on the reverse side of the form.
Examples: coins, cash, personal or cashier's check, traveler's checks, money orders, stocks, bonds.
If yes, your must complete the Customs Form 4790.

14. Mark an X in the Yes or No box. Are you or any family members traveling with you bringing commercial merchandise into the United States?

Examples: all articles intended to be sold or left in the United States, samples used for soliciting orders, or goods that are not considered personal effects.

15. If you are a U.S. resident, print the total value of all goods (including commercial merchandise) you or any family members traveling with you have purchased or acquired abroad (including gifts for someone else, but not items mailed to the United States) and are bringing into the United States.
Note: U.S. residents are normally entitled to a duty-free exemption of $800 on items accompanying them.

If you are a visitor (non-U.S. Resident), print the total value of all goods (including commercial merchandise) you or any family members traveling with you are bringing into the United States and will remain in the United States.
Note: Visitors (non-U.S. Residents) are normally entitled to an exemption of $100.

Declare all articles on this form. For gifts, please indicate the retail value. Use the reverse side of this form if additional space is needed to list the items you will declare.

The U.S. Customs officer will determine duty. Duty will be assessed at the current rate on the first $1,000 above the exemption.
  • Read the notice on the reverse side of the form.
  • Sign the form and print the date.
  • Keep the complete form with you and hand it to the CBP inspector when you approach the Customs and Border Protection area.
Controlled substances, obscene articles, and toxic substances are generally prohibited entry.

U.S. Customs and Border Protection Declaration Form - Back

BACK

U.S. Customs and Border Protection
Welcomes You to the United States

U.S. Customs and Border Protection is responsible for protecting the United States against the illegal importation of prohibited items. CBP officers have the authority to question you and to examine you and your personal property. If you are one of the travelers selected for an examination, you will be treated in a courteous, professional, and dignified manner. CBP Supervisors and Passenger Service Representatives are available to answer your questions. Comment cards are available to compliment or provide feedback.

Important Information
U.S. Residents - declare the value of all articles that you have acquired abroad and are bringing into the United States.
Visitors (Non-Residents) - declare the value of all articles that will remain in the United States.
Declare all articles on this declaration form and show the value in U.S. dollars. For gifts, please indicate the retail value.
Duty - CBP officers will determine duty. U.S. residents are normally entitled to a duty-free exemption of $800 on items accompanying them. Visitors (non-residents) are normally entitled to an exemption of $100. Duty will be assessed at the current rate on the first $1,000 above the exemption.

Controlled substances obscene articles, and toxic substances are generally prohibited entry. Agriculture products are restricted entry.
Thank You, and Welcome to the United States


The transportation of currency or monetary instruments, regardless of the amount, is legal, however, if you bring in to or take out of the United States more than $10,000 (U.S. or foreign equivalent, or a combination of both), you are required by law to file a report on FinCEN 105 (formerly Customs Form 4790) with U.S. Customs and Border Protection. Monetary instruments include coin, currency, travelers checks and bearer instruments such as personal or cashiers checks and stocks and bonds. If you have someone else carry the currency or monetary instrument for you, you must also file a report on FinCEN 105. Failure to file the required report or failure to report the total amount that you are carrying may lead to the seizure of all the currency or monetary instruments, and may subject you to civil penalties and/or criminal prosecution. SIGN ON THE OPPOSITE SIDE OF THIS FORM AFTER YOU HAVE READ THE IMPORTANT INFORMATION ABOVE AND MADE A TRUTHFUL DECLARATION.

Description of Articles
(List may continue on another CBP Form 6059B)
Value
CBP
Use Only
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Total
 


PAPERWORK REDUCTION ACT NOTICE: The Paperwork Reduction Act says we must tell you why we are collecting this information, how we will use it, and whether you have to give it to us. The information collected on this form is needed to carry out the Customs, Agriculture, and currency laws of the United States. CBP requires the information on this form to insure that travelers are complying with these laws and to allow us to figure and collect the right amount of duty and tax. Your response is mandatory. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information, unless it displays a valid OMB control number. The estimated average burden associated with this collection of information is 4 minutes per respondent or record keeper depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to U.S. Customs and Border Protection, Reports Clearance Officer, Information Services Branch, Washington D.C. 20229, and to the Office of Management and Budger, Paperwork Reduction Project (1651-0009), Washingotn D.C. 20503. THIS FORM MAY NOT BE REPRODUCED WITHOUT APPROVAL FROM THE CBP FORMS MANAGER.

*U.S. G.P.O.:2005 - 783-076/80026
CBP Form 6059B (01/04)