Taken from U.S. Customs and Border Protection site
U.S. Customs and Border Protection Declaration Form – Front
1. Print your last (family) name. Print your first (given) name. Print the first letter of your middle name.
2. Print your date of birth in the appropriate day/month/year boxes.
3. Print the number of family members traveling with you (do not include yourself).
4. Print your current street address in the United States. If you are staying at a hotel, include the hotel’s name and street address. Print the city and the state in the appropriate boxes.
5. Print the name of the country that issued your passport.
6. Print your passport number.
7. Print the name of the country where you currently live.
8. Print the name of the country(ies) that you visited on your trip prior to arriving to the United States.
9. If traveling by airline, print the airline’s name and flight number. If traveling by vessel (ship), print the vessel’s name.
10. Mark an X in the Yes or No box. Are you traveling on a business (work-related) trip?
11. Mark an X in the Yes or No box. Are you bringing with you:
||fruits, plants, food, or insects?
||meats, animals, or animal/wildlife products?
||disease agents, cell cultures, or snails?
||soil or have you visited a farm/ranch/pasture outside the United States?
12. Mark an X in the Yes or No box. Have you or any family members traveling with you been in close proximity of (such as touching or handling) livestock outside the United States?
13. Mark an X in the Yes or No box. Are you or any family members traveling with you bringing $10,000 or more in U.S. dollars or foreign equivalent in any form into the United States?
Read definition of monetary instruments on the reverse side of the form.
Examples: coins, cash, personal or cashier’s check, traveler’s checks, money orders, stocks, bonds.
If yes, your must complete the Customs Form 4790.
14. Mark an X in the Yes or No box. Are you or any family members traveling with you bringing commercial merchandise into the United States?
Examples: all articles intended to be sold or left in the United States, samples used for soliciting orders, or goods that are not considered personal effects.
15. If you are a U.S. resident, print the total value of all goods (including commercial merchandise) you or any family members traveling with you have purchased or acquired abroad (including gifts for someone else, but not items mailed to the United States) and are bringing into the United States.
Note: U.S. residents are normally entitled to a duty-free exemption of $800 on items accompanying them.
If you are a visitor (non-U.S. Resident), print the total value of all goods (including commercial merchandise) you or any family members traveling with you are bringing into the United States and will remain in the United States.
Note: Visitors (non-U.S. Residents) are normally entitled to an exemption of $100.
Declare all articles on this form. For gifts, please indicate the retail value. Use the reverse side of this form if additional space is needed to list the items you will declare.
The U.S. Customs officer will determine duty. Duty will be assessed at the current rate on the first $1,000 above the exemption.
- Read the notice on the reverse side of the form.
- Sign the form and print the date.
- Keep the complete form with you and hand it to the CBP inspector when you approach the Customs and Border Protection area.
Controlled substances, obscene articles, and toxic substances are generally prohibited entry.
U.S. Customs and Border Protection Declaration Form – Back