DEPARTMENT OF THE TREASURY
DEPARTMENT OF THE TREASURY
UNITEDSTATESCUSTOMSSERVICE SPECIAL CUSTOMS INVIOCE Form Approved
19 U.S.C. 1481, 1482, 1434 (Use separate invoice for purchased aug non-purchased goods.) O.M.B.NO.48-RO342
|1.SELLER |2. DOCUMENT NR. |3. INVOICE NR.AND DATE |
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| |4. REFERENCES |
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|5. CONSIGNEE |6. BUYER (if other than consignee) |
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| |7. ORIGIN OF GOODS |
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|8. NOTIFY PARTY |9. TERMS OF SALE PAYMENT AND DISCOUNT |
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|10. ADDITIONAL TRANSPORTATION INFORMATION | |
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| |11.CURRENCY USED |12.EXCH.RATE(if fixed or |13.DATE ORDER ACCEPT |
| | |agreed) | |
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|14. |15. |16. |17. |UNIT PRICE |20. |
|MARKS AND NUMBERS ON SHIPPING |NUMBEF OF |FULL DESCRIPTION |QUANTITY | |INVOICE |
|PACKAGES |PACKAGES |OF GOODS | | |TOTALS |
| | | | |18.HOME |19. NVOICE | |
| | | | |MARKET | | |
|21. If the production of these goods involved furnishing goods or services to the seller (e.g., assists such|22. PACKING COSTS | |
|as dies. molds. | | |
|Tools, engineering work) and the value is not included in the invoice price, check box (21) and explain below. | | |
|27. DECLARATION OF SELLER/SHIPPER (OR AGENT) |23. OCEAN OR | |
| |INTERNATIONAL | |
| |FREIGHT | |
|I declare. | | | |
| | | | |
|If there are any rebates, drawbacks or |If the goods were not sold or agreed to be sold, I have hecked | | |
|Bounties allowed upon the exportation |(B) box(B) and have indicated in column 19 the Price I would | | |
|of goods, I have checked box (A) and |be | | |
|itemized separately boelow. |willing to receive. | | |
|I further declare that there is no other invoice | | | |
|Differing from this one(unless otherwise |(C) SIGNATURE OF SELLER/SHIPPER(OR AGENT): | | |
|described | | | |
|Below) and that all statements contained in this| | | |
|Invoice and declaration are true and correct. | | | |
| | |24. DOMESTIC | |
| | |FREIGHT CHARGES | |
| | |25. INSURANCE | |
| | |COSTS | |
| | |26. OTHR COSTS | |
| | |(Specify Below) | |
|28. THIS SPACE FOR CONTINUING ANSWERS |
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|THIS FORM OF INVOICE REOUIRED GENERALLY IF RATE OF DUTY BASED UPON OR REGULATED BY VALUE OF GOODS AND PURCHASE PRICE OR VALUE OF SHIPMENT ESCEEDS $ 500, OTHERWISE USE |
|COMMERCIAI, INVOICE |
|Not necessary for U.S. Customs purposes. Customs Form 5515 (12-20-76) |
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