---
type: travel-doc
category: travel
person: Xue Fengqin
date: 
source: customs_xue_fengqin.jpg
---

# Customs Declaration (English Version) - Xue Fengqin

**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 |

Read the instructions on the back of this form. Space is provided to list all the items you must declare.

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

**Signature:** *(signed)*
**Date:** —