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[[pre-printed]]
Form No. 253
FOREIGN SERVICE
(Amended March 1944)

FOREIGN SERVICE OF THE UNITED STATES OF AMERICA
[[line]]
DECLARATION IN CONNECTION WITH PAINTINGS, ETC., AND SCULPTURES
To be entered under Paragraph 1807 of the Tariff Act of 1930
[[line]]

^[[Zurich, August 14th, 1957]]
(Place and date)

I,* ^[[F. Rusconi, Wasserwerkstr. 6, [[underline]]Zurich 6[[/underline]] ]]do hereby declare that I am the [[strikethrough]]painter or producer[[/strikethrough]] ^[[shipper]] of certain works of art, viz:

^[[ [[strikethrough]]No. 8492[[/strikethrough]] Marble Bas-Relief "Virgin & Child"with two Cherubs on top corner" [[underline]]packed in one twofold wooden case, marked JS & Co 3, total gross weight 89 kos.[[/underline]], total net weight 27,5 kos.]]

covered by consular invoice No. ______, certified by the American Consul at ______

on the ______ day of ______, 19__; that the said paintings, pastels, drawings, and sketches are originals; [[underline]]that the said sculptures or statuary are originals[[/underline]] or the first or second replicas; and that the said etchings, engravings, or woodcuts were printed by hand from hand-etched or hand-engraved plates or blocks and [[underline]]are artists' proofs[[/underline]] ^[[attributed to Francesco di Simoni second half 15th. cent.]]

^[[ [[underline]]Port of Entry:[[/underline]] New York Intern. Airport
[[underline]]Cosignee:[[/underline]] Mr. Germain SELIGMAN
c/o Jaques Seligman & Co. Inc.
5 East 57th Street
[[underline]]NEW YORK 22, N.Y.[[/underline]] ]]
}SS:

[[signed]]F. Rusconi[[/signed]]
(Signature of [[strikethrough]]artist or shipper)
[[/strikethrough]] ^[[shipper]]
^[[F. Rusconi,
Wasserwerkstr. 6
Zurich 6]]

[[line]]
^[[- CONSULAR LEGALIZATION NO LONGER REQUIRED -]]

I, ______, Consul of the United States of America at ______, do hereby certify that the above declaration was subscribed and sworn to (or affirmed) before me by ______ on this ______ day of ______, 19 __, and that the statements therein contained are true to the best of my knowledge and belief.

[[signature line]]
Consul of the United States of America.

No fee when issued with a consular invoice.
[[line]]
*If declared to by the foreign shipper the form should be changed to conform thereto, and a statement embodied therein showing why it was impracticable to obtain the declaration of the artist.

U. S. GOVERNMENT PRINTING OFFICE 16-10608-2[[/pre-printed]]