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Address
3. Represented Locally By: Name Address Phone
Phone No.
4. Vessel Name 5. IMO No. 6. Name of Master 21. Surety Name and Number
7. Last U.S. Departure Port 8. Last U.S. Departure Date 22. Bond: Single Transaction 23. Bond Amt.
Continuous Bond
9. Foreign Port Arrived From 10. Voyage No. 11. U.S. Port of Arrival 12. Port Code 13. Arrival Date
No.
14. 15. 16. 24. 25. 26.
Location (City and Country) and Sailing Description of Work Performed Including Identification of Cost in foreign Money Exchange Entered Duty @ 50% Entered
Date from that Country Materials/Equipment Purchased Rate U.S. cost Cost in U.S. Money
17B. Title 17C. Date 18B. Title 18C. Date 28B. Title 28C. Date
PAPERWORK REDUCTION ACT NOTICE : This request is in accordance with the Paperwork Reduction Act. We ask for the information in order to carry out the laws and regulations administered by U.S.
Customs and Border Protection. These regulations and form require the master of a vessel to make entry on the cost of equipment, or any part thereof purchased, of repair parts or material used or of repairs
made in a foreign country. It is mandatory. The estimated average burden associated with collection of information is 30 minutes per respondent depending on individual circumstances. Comments concerning
the accuracy of this burden estimate and suggestions for reducing this burden should be direct to U.S. Customs and Border Protection, Asset Management, Washington, DC 20229 and to the Office of
Management and Budget, Paperwork Reduction Project (1651-0027) Washington, DC 20503.