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[[preprinted]]
Form FFC 168
Treasury Department 
FOREIGN FUNDS CONTROL

[[underline]] REPORT [[/underline]]

[[underline]] (This report must be executed in duplicate and attached to application Form TFE-1 under the provisions of T. D. 51072, relating to the release of art objects from customs custody) [[/underline]]

1. (a) Entry No.: [[blank line]]
   (b) Port of entry: [[blank line]]
   (c) Date of importation: [[blank line]]
   (d) Country of export: [[blank line]]
   (e) Date of export shipment: [[blank line]]

2. Description of art object -
   (a) Category (painting, sculpture, ceramics, etc.): [[blank line]]
   (b) Title of work, if any: [[blank line]]
   (c) Material composition: [[blank line]]
   (d) Dimensions (without frame, mat, pedestal, etc.): [[blank line]]
   (e) Name of foreign country in which art object was created: [[blank line]]
   (f) Name of artist or craftsman: [[blank line]]
   (g) Approximate date of work: [[blank line]]
   (h) Distinctive markings, if any: [[blank line]]

3. State whether the art object has been exhibited in any exhibition, museum, or gallery....If so, give details: [[blank line]]

4. Information concerning the consignor:
   (a) Name: [[blank line]]
   (b) Address: [[blank line]]
   (c) Nationality, under Executive Order No. 8389, as amended: [[blank line]]

5. Information concerning the consignee:
   (a) Name: [[blank line]]
   (b) Address: [[blank line]]
   (c) Nationality, under Executive Order No. 8389, as amended: [[blank line]]
[[/preprinted]]