I, 
DECLARATION FOR RELEASE UNDER THE $200 OR $300 EXEMPTION OF ARTICLES 
ACQUIRED ABROAD BY RETURNING RESIDENTS OF THE UNITED. STATES 
______ , declare that I am a resident of 
( City and State) 
the United States on or about 
: ■ that I last departed from 
* 
States on my return at the port of 
on or about 
( Date) 
that I arrived in the United 
or vessel) 
abroad the _ 
( Name of airline 
that I filed a declaration as 
( Date ) 
a resident of the United States returning from abroad wherein the following 
articles which were acquired by me or members of my family but did not accom¬ 
pany me at the time of my above-mentioned arrival in this country, were de¬ 
clared for the purpose of obtaining for those articles the personal exemptions 
to which United States residents returning from abroad are entitled: 
ARTICLES 
DECLARED VALUE 
» 4 
I further declare that upon my return I was accompanied by __ 
{ Name & relationship) 
_, all members of my family; that all the articles described,above are 
for.tne persona.'., use of myself or members of my family who ac?ovtinanted.me3 that 
noi:,e of the articles enumerated above are the property of any other person, nor 
wore they purchased or. commission for any other person, or for sale; and. that, 
to the fc»'st of my knowledged and belief, the values, of the articles are within 
the total amounts of the exemptions to which I am entitled by law. 
It is understood uha0 my right to have the articles nsoed above. exemoted from 
the payment of duty will be verified after their release and I hereby agree to 
pay any customs duties or internal-revenue taxes assessed on any of tile articles 
not entitled to free entry promptly upon receipt of notice of the amount due. 
( Signature) 
PERMANENT ADDRESS 
(.Number) (Street) (City) (state) 
WARNING: 
ANY FALSE STATEMENT MADE HEREIN NI nL SUBJECT THE MERCHANDISE TO 
PORjllTUHE OR THE PEClARANT TO A PEiIAnTY EQUAL' TO TIE VAuUE OF THE 
MERCHANDISE IN THE UNITED STATES. (19 U. S. C. 2$ ft). 
