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CBP Form 4455 Forms US Customs and Border Protection 2012
FOR:
ALTERATION*
REPAIR*
USE ABROAD
REPLACEMENT
PROCESSING*
OTHER, (specify)
* NOTE: The cost or value of alterations, repairs, or processing abroad
is subject to CBP duty.
LIST ARTICLES EXPORTED
Number
Packages
Kind of
Packages
Description
DATE
SIGNATURE OF OWNER OR AGENT (Print or Type and Sign)
The Above-Described Articles Were:
DATE
EXAMINED
PORT
SIGNATURE OF CBP OFFICER
DATE
LADEN under my supervision
PORT
SIGNATURE OF CBP OFFICER
CERTIFICATE ON RETURN
Duty-free entry is...
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