Simplified Customs Declaration

Import
To Be Used Only For Personal & Household Effects (Form C. 73­ Customs)
or Non­commercial Items. (Reg. 31)
Please Use Capital (block) Letters

1 TIN No. 2 DATE

Y Y M M D D

3 FIRST NAME

SURNAME

4 PASSPORT/ID No.

5 ADDRESS OF IMPORTER

6 BILL OF LADING/AIRW AY BILL No.

7 PORT OF ARRIVAL

8 NAME OF VESSEL/AIRCRAFT

9 COUNTRY OF CONSIGNMENT

10 DATE OF REPORT
Y Y M M D D

11 ROTATION # 12 GROSS W EIGHT (kgs)

13 No. & KIND OF PACKAGE(s)

18 FOR OFFICIAL USE ONLY

14 Contents of Package 15 Commodity 16 Declared Assessed Import Other VAT TOTAL
Code Value Value Duty Taxes
$ $ $ $ $ $

GRAND TOTAL

17 I/We hereby declare that the information and particulars mentioned 19 Validated for Payment
herein are true and correct.

______________________________________ ____________________________________
Signature of Declarant/Agent for Commissioner of Customs & Trade Administration

NOTE: Penalties will be imposed under the Customs Act, Chapter 82:01 for making a false declaration.

Please read instructions for the completion of this form overleaf.