Customs Form 5129 - Crew Member'S Declaration printable pdf download

DEPARTMENT OF THE TREASURY

UNITED

STATES

CUSTOMS

SERVICE

Form Approved

OMS

No.1515-<J063:

See

back

of form for Paperwork

Reduction

Act Notice

11.

Crew Member's Article No.

CREW MEMBER'S DECLARATION

19 CFR 47, 4.7a, 4.81,122.83,122.84,148.61-67

K0521902

The Customs officer accepting the declaration and entry shall draw lines through unused spaces on receipt with ink.

Notice: Liquidation of amount of duties and taxes, if any, due on this entry is effective on date cf payment 9f this amount (Section 159.10,

CR.)

For importer's right to protest or Government's

right to redetermine

this amount, see section 514 Tariff Act of 1930 as amended.

Customs Form 5129 (02/01)

2. Carrier (Vessel Flag, Name)

3. Date of Arrival

4. Port of Arrival

5.Crew

Member's

Name

6. Rank

7. Date

of Birth

INSTRUCTIONS

List all articles obtained abroad and prices paid or fair

value if not purchased. Include senal number with all

8. Address

articles subject to registration such as cameras. radios.

etc.

9. Answer

Each

Question:

List articles to remain on board separately from those

A. Are you carrying any fruits,

B. Have you been on a

C. Are you carrying over $10,000 in monetary

articles to be landed in the United States.

plants, meats, other plant or

farm or ranch outside

instruments, such as coin, currency, travelers

animal products, birds, snails,

the U.S.A. in the last

checks, money orders, or negotiable instruments

List separately articles intended for sale, barter,

or other live organisms of any

30 days?

in bearer form? (yes, you must file a report on

exchange, or carried by you as an accommodation for

kind?

CF 4790.)

someone else.

DYes

See additional instructions and information on reverse.

J.To be filled in by Crew Member

II. For Customs Officer's Use

Quantity and Description of Goods

Cost or Value of

Tariff Description

Value

Rate

Duty

Gifts,etc.

I certify

that the above

statement

is a just,

true and complete

account

of all articles

of foreign

origin

for which

written

declaration

and entry are required when landed in the United States (defined on reverse side) and I also certify that this

TOTAL

statement is a just, true, and complete declaration

of all such articles which I am landing in the United States.

_::

:_s-

i_c_e:-

_t:

_r--

-- m -- - - - _m J:::

:t:_:

__--m

-- - - _m-

---- -- - -- -- --

12. Date

-- - - - - -- _n -- - - - - - - - ---- - - ---

RECEIPT FOR DUTY AND RELEASE SLIP

Port

Crew Member's Article No.

To be filled in by Crew Member

Name

Carrier

K0521902

Repeat List of Articles to Be Landed (include serial numbers when appropriate)

For Customs

Officer's

Use

Date

Duty

Articleslistedat lefthavebeenexam inedandpassed

Pieces of Baggage

Released:

of Customs

Customs Form 5129 - Crew Member'S Declaration

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