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DECLARATION OF NOMINAL CONSIGNEE, CONSIGNEE, OR AGENT OF CONSIGNEE

To the best of my knowledge and belief, all statements appearing in this entry and in the invoice or invoices and other documents presented herewith and in accordance with which the entry is made, are true and correct in every respect; the entry and invoices set forth the true prices, values, quantities, and all information as required by the laws and the regulations made in pursuance thereof; the invoices and other documents are in the same state as when received; I have not received and do not know of any other invoice, paper, letter, document, or information showing a different currency price, value, quantity, or description of the said merchandise, and if at any time hereafter I discover any information showing a different state of facts I will immediately make the same known to the District Director of Customs at the port of entry.

If the merchandise is entered by means of a seller's or shipper's invoice, no customs invoice for any of the merchandise covered by the said seller's or shipper's invoice can be produced due to causes beyond my control. If the merchandise is entered by means of a statement of the value or the price paid in the form of an invoice, it is because neither seller's, shipper's, nor customs invoice can be produced at this time.

CARRIER'S CERTIFICATE AND RELEASE ORDER

Date

The undersigned carrier, to whom or upon whose order the articles described herein or in the attached document must be released, hereby certifies that the consignee named in this document is the owner or consignee of such articles within the purview of section 484(h), Tariff Act of 1930. In accordance with the provisions of section 484(j), Tariff Act of 1930, authority is hereby given to release the articles covered by the aforementioned statement to such consignee.

(Name of carrier)
(Agent)


AUTHORITY TO MAKE ENTRY FOR PORTION OF CONSOLIDATED SHIPMENT

The merchandise covered by this entry or such portion thereof as may be specifically indicated was shipped by 
consigned to 
endorsed to 
covered by *
dated ... at .... on file with the district director of customs at .
I }
We} the consignee in the above mentioned document covering merchandise for various ultimate consignees, hereby authorize ... or order to make customs entry for the merchandise.

(Consignee)

(Transfer of the above authority may be made by endorsement here.)
*Insert "Bill of lading," "Certified duplicate bill of lading," "Carrier's certificate," or "Shipping receipt."

Note:

Term Bond No.-If single entry bond is filed insert "S.E." 
Importing Vessel or Carrier.--Show the name of vessel or carrier and motive power. If imported by plane or train show also flight or train number.
Type and Date of Invoice.-If entry includes more than one invoice show number of invoices and include information for each invoice in the body of the form in column provided for Description of Merchandise.
Duty and I.R. Tax.-Show separately amount of duty, internal revenue tax, and/or tea inspection fee on each item listed. Internal revenue tax assessments should be preceded by the letters "IR." Tea inspection assessments should be preceded by the letters "TI." If the entry represents more than one dutiable item, the amounts of duty, internal revenue tax, and tea inspection fee should be totaled and labeled separately "Total Duties," "Total I.R. Tax," and/or "Total T.I. Fee" and recorded together with an aggregate total labeled "Total Collections" in the extreme lower portion of this column.

For information relative to the preparation and filing of a customs entry see UNITED STATES CUSTOMS REGULATIONS and TARIFF SCHEDULES OF THE UNITED STATES ANNOTATED FOR STATISTICAL REPORTING.

BROKER OR AGENT
(Name) (Address)