I, ______________________,
declare that to the best of my knowledge and belief the articles herein specified were exported from the United States, from the port of ________________ on or about ________________, 20____, and that they are returned without having been advanced in value or improved in condition by any process of manufacture or other means.
Marks | Number | Quantity | Description | Value, in U.S. coin |
(Date) | (Signature) | |||
(Address) | (Capacity) |
I, ______________,
declare that the (above) (attached) declaration by the foreign shipper is true and correct to the best of my knowledge and belief, that the articles were manufactured by ________________ (name of manufacturer) located in ________________ (city and state), that the articles were not manufactured or produced in the United States under subheading 9813.00.05, HTSUS, and that the articles were exported from the United States without benefit of drawback.
_______________________________
(Date)
_______________________________
(Address)
_______________________________
(Signature)
_______________________________
(Capacity)
19 C.F.R. §10.1