59 lines
2.1 KiB
Markdown
59 lines
2.1 KiB
Markdown
---
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type: travel document
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category: customs declaration form
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person: Xue Fengqin
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date:
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source: customs_xue_fengqin.jpg
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---
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# Customs Declaration (English Version) - Xue Fengqin
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**U.S. Customs and Border Protection**
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19 CFR 122.27, 148.12, 148.13, 148.110, 148.111, 1498; 31 CFR 5316
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FORM APPROVED OMB NO. 1651-0009
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Each arriving traveler or responsible family member must provide the following information (only ONE written declaration per family is required):
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| # | Field | Value |
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|---|---|---|
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| 1 | Family Name | Xue |
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| | First (Given) | Fengqin |
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| | Middle | — |
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| 2 | Birth date | Day 06 Month 04 Year 65 |
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| 3 | Number of Family members traveling with you | 2 |
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| 4(a) | U.S. Street Address (hotel name/destination) | 1652 W 6th Street Apt. R |
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| 4(b) | City | Austin |
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| 4(c) | State | Texas |
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| 5 | Passport issued by (country) | China |
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| 6 | Passport number | G49056250 |
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| 7 | Country of Residence | China |
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| 8 | Countries visited on this trip prior to U.S. arrival | China |
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| 9 | Airline/Flight No. or Vessel Name | HU 495 |
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## Declaration Questions
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| # | Question | Answer |
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|---|---|---|
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| 10 | The primary purpose of this trip is business | No X |
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| 11(a) | fruits, vegetables, plants, seeds, food, insects | No X |
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| 11(b) | meats, animals, animal/wildlife products | No X |
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| 11(c) | disease agents, cell cultures, snails | No X |
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| 11(d) | soil or have been on a farm/ranch/pasture | No X |
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| 12 | I have (We have) been in close proximity of (such as touching or handling) livestock | No X |
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| 13 | I am (We are) carrying currency or monetary instruments over $10,000 U.S. or foreign equivalent | No X |
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| 14 | I have (We have) commercial merchandise | No X |
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## Declared Value
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| Category | Value |
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|---|---|
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| 15. Residents — total value of all goods | $ — |
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| Visitors — total value of all articles that will remain in the U.S., including commercial merchandise | $ 500 |
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Read the instructions on the back of this form. Space is provided to list all the items you must declare.
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**I HAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF THIS FORM AND HAVE MADE A TRUTHFUL DECLARATION.**
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**Signature:** *(signed)*
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**Date:** —
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