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FOR CUSTOMS CLEARANCE BY

PARTIES TO THIS TRANSACTION ARE

U.S. DUTY / BROKERAGE FOR ACCOUNT OF:

CURRENCY OF SALE

Customer Order Information
  • COUNTRY OF ORIGIN
  • DESCRIPTION OF GOODS
  • TEN DIGIT H.T.S. NUMBER
  • UNIT QTY.
  • UNIT PRICE
  • INVOICE TOTAL
If food is being imported, have any of the food items on this shipment been refused by any other countries?
INVOICE TOTAL

ABOVE PRICES INCLUDE

DECLARATION BY FOREIGN SHIPPER (To be completed only when the goods described above are of U.S. origin and their value exceeds $500.00

I

declare that the articles herein specified are to the best of my knowledge and belief, the growth, produce or manufacture of the United

States: That they were exported from the United States from the port of

on or about

that they are returned

without having been advanced in value or improved in condition by any process of manufacture or other means. Any shipment that contains U.S. goods returned valued over $2,500 should have a manufacturer’s affidavit attached to this invoice.

SHIPPER

SIGNATURE

DATE SIGNED

To the best of the knowledge and belief of the preparer this invoice is true and complete and discloses the true prices, values, quantities, rebates, drawbacks, fees, commissions, royalties and any goods or services provided to the seller either free orat a reduced cost.