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[[[preprinted]] Form 7525-V (rev. Nov. 1948) Export Control Foreign Commerce Statistical Regulations (See Instructions on Reverse Side) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS - OFFICE OF INTERNATIONAL TRADE SHIPPER'S EXPORT DECLARATION OF SHIPMENTS TO FOREIGN COUNTRIES OR NONCONTIGUOUS TERRITORIES OF THE UNITED STATES READ CAREFULLY THE INSTRUCTIONS ON BACK TO AVOID DELAY AT SHIPPING POINT Clearance will not be granted until shipper's declaration has been filed with the collector of Customs. This declaration shall not be used to effect any exportation after the expiration date of the export license referred to herein, except as specifically authorized by expert regulations. DECLARATIONS SHOULD BE TYPEWRITTEN OR PREPARED IN INK; INDELIBLE PENCIL IS NOT PERMISSIBLE. Form Approved Budget Bureau No. 41-RS97.2. Confidential Do Not Use This Area ^[[signature]] Buhrle[[/signature]] File No. (This Space for Use of Customs) Do Not Use This Area | District | Port | Country (For customs use only) 1. Exporting Carrier (if vessel, give name, flag, and pier number) [[KLM Royal Dutch Airlines]] 2. From (U.S. Port of Export) [[New York]] 3. Exporter (Principal or seller - licensee) [[Jacques Seligmann & Co., Inc.]] Address (Number, street, place, State) [[5 East 57th St. New York 22, N.Y.]] 4. Agent of Exporter (Forwarding agent) [[?]] none Address (Number, street, place, State) 5. Purchaser or Ultimate Consignee [[Emil Buhrle]] Address (Place, country) 178 Zoillikerstr, Zurich, Switzerland 6. Intermediate Consignee [[none]] 7. Foreign Port of Unloading (For vessel and air shipments only) [[Zurich, Switzerland]] 8. Place and Country of Ultimate Destination (Not place of transshipment) [[Zurich, Switzerland]] [[7 columns]] (9) Marks and Nos.|(10) Number and Kind of Packages, Description of Commodities, Export License Number, Issuance Date, Expiration Date (or General License Symbol) (Describe commodities in sufficient detail to permit classification according to Schedule B. Do not use general terms. Insert required license information on line below description of each item)| (11) Shipping Weight* (Gross weight in pounds) Not required for truck, rail, and mail exportations| (12) Specify "D" or "F"| (13) Schedule B Commodity No.| (14) Net Quantity in schedule B units (State unit)| (15) Value at Time and Place of Export (Selling price or cost if not sold, including inland freight, insurance and other charges to place of export) (Nearest whole dollar; omit cents) J.S. 1|(painting by Degas "Danseuses (au Foyer"|127)|F| |22 Lbs.| $35,500 |(painting by Matisse "Carnival(de Nice"|Lbs)|F| |24 Lbs.|$11,500 [[/7 columns]] 16. Waybill or Manifest No. (of Exporting Carrier) 17. Date of Exportation (if Vessel, Date of Clearance) 18. The Undersigned Hereby Authorizes..... (Name and address - Number, street, place, State) to Act as Forwarding Agent for Export Control and Customs Purposes. Exporter.....by (Duly Authorized Officer or Employee) 19. I Declare That All Statements Made and All Information Contained in This Export Declaration Are True and Correct 20. Subscribed and sworn to before me on [[22nd, June, 1961]] Signature.....(Duly authorized officer or employee of exporter or named forwarding agent) For (Name of corporation or firm and capacity of signer, e.g. secretary, export manager, etc.) [?] (Title or Designation) Notary Public, etc., or those authorized to administer oaths under Sec 486, Tariff Act of 1930. Address [?] St., New York 22, N.Y. Declaration should be made by duly authorized officer or employee of exporter or of forwarding agent named by exporter. *If shipping weight is not available for each Schedule B item listed in column (13) included in one or more packages, insert the approximate gross weight for each Schedule B item. The total of these estimated weights should equal the actual weight of the entire package or packages. *Designate foreign merchandise (reexports) with an "F" and exports of domestic merchandise produced in the United States or changed in condition in the United States with a "D". No authenticated declaration relating to any commodity requiring an export license may be altered, changed, or amended without prior written authorization from the collector of customs or from such other person as may be empowered by export regulations to give such written authorization. (See also Instruction 2 (e).) 16-56693-1
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