---
type: travel-doc
category: travel
person: Jiang Xianlu, Xue Fengqin
date: 
source: 海关申报表.pdf
---

# Page 1: 海关申报单 (Customs Declaration - Chinese Version)

**U.S. Customs and Border Protection**
19 CFR 122.27, 148.12, 148.13, 148.110, 148.111, 1498; 31 CFR 5316
批准表格 OMB NO. 1651-0009

每位入境旅客或家庭负责人必须提供以下资料（每个家庭只需填写一份申报单）：

| # | Field (Chinese) | Value |
|---|---|---|
| 1 | 姓 | Jiang |
| | 名 | Xianlu |
| | 中间名 | — |
| 2 | 出生日期 | 日 28 月 01 年 68 |
| 3 | 随行家庭成员人数 | 2 |
| 4(a) | 在美国的地址街名（旅馆名称/目的地） | 1652 W 6th Street Apt. R |
| 4(b) | 市 | Austin |
| 4(c) | 州 | Texas |
| 5 | 发照地（国家） | China |
| 6 | 护照号码 | E38284127 |
| 7 | 居住国 | China |
| 8 | 这次抵达美国之前曾去过的国家 | China |
| 9 | 航空公司/班机号码或船名 | HU 495 |

### 申报问题

| # | Question | Answer |
|---|---|---|
| 10 | 这次旅行的主要目的是业务出差 | 否 X |
| 11(a) | 水果、蔬菜、植物、种子、食品、昆虫 | 否 X |
| 11(b) | 肉类、动物、动物/野生动物产品 | 否 X |
| 11(c) | 疾病媒体、细胞培养体、蜗牛 | 否 X |
| 11(d) | 土壤或曾经到过农场/牧场/饲养场 | 否 X |
| 12 | 曾经非常接近（如摸过或者处理过）牲畜 | 否 X |
| 13 | 携带超过 10,000 美元或相等数额的外国货币的现金或代金 | 否 X |
| 14 | 携带商品（可供销售的物品、用于招揽订单的样品、或不属于个人用品的物品） | 否 X |

### 申报价值

| Category | Value |
|---|---|
| 15. 居民 — 总价值 | $ — |
| 来访者 — 将留在美国的所有物品（包括商品）的总价值 | $ 500 |

**签名:** *(signed)*
**日期:** —

---

# Page 2: Customs Declaration (English Version)

**U.S. Customs and Border Protection**
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):

| # | Field | Value |
|---|---|---|
| 1 | Family Name | Xue |
| | First (Given) | Fengqin |
| | Middle | — |
| 2 | Birth date | Day 06 Month 04 Year 65 |
| 3 | Number of Family members traveling with you | 2 |
| 4(a) | U.S. Street Address (hotel name/destination) | 1652 W 6th Street Apt. R |
| 4(b) | City | Austin |
| 4(c) | State | Texas |
| 5 | Passport issued by (country) | China |
| 6 | Passport number | G49056250 |
| 7 | Country of Residence | China |
| 8 | Countries visited on this trip prior to U.S. arrival | China |
| 9 | Airline/Flight No. or Vessel Name | HU 495 |

### Declaration Questions

| # | Question | Answer |
|---|---|---|
| 10 | The primary purpose of this trip is business | No X |
| 11(a) | fruits, vegetables, plants, seeds, food, insects | No X |
| 11(b) | meats, animals, animal/wildlife products | No X |
| 11(c) | disease agents, cell cultures, snails | No X |
| 11(d) | soil or have been on a farm/ranch/pasture | No X |
| 12 | I have (We have) been in close proximity of (such as touching or handling) livestock | No X |
| 13 | I am (We are) carrying currency or monetary instruments over $10,000 U.S. or foreign equivalent | No X |
| 14 | I have (We have) commercial merchandise | No X |

### Declared Value

| Category | Value |
|---|---|
| 15. Residents — total value of all goods | $ — |
| Visitors — total value of all articles that will remain in the U.S., including commercial merchandise | $ 500 |

**I HAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF THIS FORM AND HAVE MADE A TRUTHFUL DECLARATION.**

**Signature:** *(signed)*
**Date:** —