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All Blanks in these Three Columns to be filled in by Shipper. The form of Invoice on the other side to be used.

[FORM NO. 140]

CERTIFICATE 

undersigned, Deputy-Consul-General States, do hereby certify that, on day of   , A.D. 190  , described in the indorsement hereof was to me by the signer of the annexed declaration.

further certify that I am satisfied that the person the declaration hereto annexed is the person he resents himself to be, and the actual market value wholesale price of the merchandise described in the said invoice in the principal markets of the country at the time of exportation is correct and true, excepting as noted by me said invoice, or respecting which I shall make special communication to the proper authorities.

Fee $2.50 United States gold, paid by affixing stamp to the DUPLICATE copy of the document.
Witness my hand and seal of office the day and year aforesaid.
Received the equivalent of $2.50 in gold.
G. Mayer
Deputy United States Consul-General, London, England.

Directions.

1. Full names of Deponent.
2. Address.
3.'Purchaser or "Seller"
4.Date
5. Port.
6. Signature of Deponent.

[FORM NO. 138.]

Declaration of Purchaser or Seller.

I 1, Gus Mayer the undersigned, of 2 168 New Bond ST. YY do solemnly and truly declare that I am 3 Seller.

of the merchandise in the within invoice mentioned and described; that the said invoice is in all respects correct and true, and was made at L O N D O N, whence said merchandise is to be exported to the United States; that said invoice contains a true and full statement of the time when, the place where, and the person from whom the same was purchased, and the actual cost thereof, price actually paid or to be paid therefor, and all charges thereon; that no discounts, bounties or drawbacks are contained in said invoice but such as have been actually allowed thereon; that no different invoice of the merchandise mentioned in said invoice has been or will be furnished to any one, and that the current in which said invoice is made out is that which was actually paid or is to be paid for said merchandise.

I further declare that it is intended to make entry of said merchandise at the port of5 Detroit Mich. in the United States of America.
Dated at L O N D O N, this 14 day of September, 1906
6 Gus Mayer

PURCHASED BY IMPORTER.

21405

Invoice No} (leave blank.)
Here mark the forms "original," "Duplicate," & "Triplicate" respectively:
quadruplicate
Issued in } Triplicate. Quadruplicate.

Consulate-General of the United States,
AT
LONDON, ENGLAND

Date 14 September, 1906
Sellers: Obach & Co.
Address 168 New Bond ST. NY
Purchaser: C. L. Freer Esq.
33 Ferry Avenue, Detroit Mich.
Name of vessel SS St Louis
Port of Shipment, LONDON.
Port of arrival New York.
Port of entry Detroit
Value £71
Contents Picture.

LONDON, ENGLAND
CUSTOM-HOUSE INDORSEMENT.*
No.
Importer
Vessel
From
Arrived
Kind of Entry:

Marks, Quantity, and Contents:

*Consular officers will leave all of the above indorsement blank. It is to be filled in only at the custom house at the port of entry.

Transcription Notes:
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