DEPARTMENT OF HOMELAND SECURITY
U.S. Customs and Border Protection
3. Summary Date
4. Surety No.
7. Entry Date
ENTRY SUMMARY
9. Mode of Transport
10. Country of Origin
11. Import Date
12. B/L or AWB No.
13. Manufacturer ID
14. Exporting Country
15. Export Date
16. I.T. No.
17. I.T. Date
18. Missing Docs 19. Foreign Port of Lading
20. U.S. Port of Unlading
21. Location of Goods/G.O. No.
22. Consignee No.
23. Importer No.
24. Reference No.
25. Ultimate Consignee Name and Address
26. Importer of Record Name and Address
27.
28. Description of Merchandise
32.
33.
34.
29.
30.
31.
Duty and I.R. Tax
Line
No.
Dollars
Cents
35. Total Entered Value
CBP USE ONLY
TOTALS
Other Fee Summary for Block 39
A. LIQ CODE
B. Ascertained Duty
37. Duty
REASON CODE C. Ascertained Tax
38. Tax
D. Ascertained Other
39. Other
E. Ascertained Total
40. Total
SIGNATURE
DATE
42. Broker/Filer Information (Name, address, phone number)
43. Broker/Importer File No.
CBP Form 7501 (06/09)
8. Importing Carrier
TITLE
41. DECLARANT NAME
1. Filer Code/Entry No.
2. Entry Type
36. DECLARATION OF IMPORTER OF RECORD (OWNER
OR PURCHASER) OR AUTHORIZED AGENT
Form Approved OMB No. 1651-0022
EXP. 03-31-2012
City
State
Zip
City
State
Zip
$
Total Other Fees
$
I declare that I am the
I also declare that the statements in the documents herein filed fully disclose to the best
of my knowledge and belief the true prices, values, quantities, rebates, drawbacks, fees, commissions, and royalties and are true and correct, and that all
goods or services provided to the seller of the merchandise either free or at reduced cost are fully disclosed.
Importer of record and that the actual owner,
was not obtained pursuant to a purchase or agreement to purchase and the statements in the invoices as
to value or price are true to the best of my knowledge and belief.
I will immediately furnish to the appropriate CBP officer any information showing a different statement of facts.
or purchaser or agent thereof.
purchaser, or consignee for CBP purposes is as shown above,
owner