I, ____________________ (name) of ____________________ (organization) do hereby declare that to the best of my knowledge and belief the goods identified below were sent directly from the United States on ____________, 20____, to ____________________ (name) of ____________________ (organization) on ____________________ (insular possession) via the ____________________ (name of carrier) and that the goods remained in said insular possession until shipped by me directly to the United States via the ____________________ (name of carrier) on ____________, 20____.
Marks | Numbers | Quantity | Description | Value |
Dated at ________________, this ________ day of ____________, 20____.
Signature:_______________________________
I, ____________________ (name), of ____________________ (organization) declare that the (above) (attached) declaration by the shipper in the insular possession is true and correct to the best of my knowledge and belief, that the goods in question were previously imported into the customs territory of the United States and were shipped to the insular possession from the United States without remission, refund or drawback of any duties or taxes paid in connection with that prior importation, and that the goods arrived in the United States directly from the insular possession via the ____________________ (name of carrier) on ____________, 20____.
_______________________________
(Date)
_______________________________
(Signature)
19 C.F.R. §7.3