Form 5125 Application for Withdrawal Bonded Stores for Fishing Ves

OMB No. 1651-0092
Exp. 04-30-2009

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
APPLICATION FOR WITHDRAWAL OF BONDED STORES
FOR FISHING VESSEL AND CERTIFICATE OF USE
19 U.S.C. 1309, 1317; 19 CFR 10.59, 10.65; 27 CFR 290; CD 099-3260-050
1. NAME OF VESSEL

2. VESSEL I.D. NUMBER

3. DOCUMENT NO.

4. HOME PORT

5. PLACE OF DEPARTURE

6. DESTINATION

7. DATE OF DEPARTURE

8. LENGTH OF VOYAGE (DAYS)

10a. NAMES (CREW MEMBER)

9. NO. OF CREW ON VESSEL

10b. ADDRESSES

10. PORT OF RETURN

10c. SOCIAL SECURITY NUMBERS

THIS APPLICATION IS HEREBY MADE for the conditionally free withdrawal, under Section 309 of the Tariff Act of 1930, as amended, of the
following articles to be used exclusively as supplies on the vessel during the voyage:
11. LIST OF ARTICLES

In making this application, I am aware of the provisions of law relating to a false declaration and I stipulate and agree to be bound by the
conditions specified below upon arrival.
12. DATE

13. SIGNATURE OF WITHDRAWER

X
APPLICATION APPROVED SUBJECT TO THE FOLLOWING CONDITIONS:
(1) That this application shall be presented by the withdrawer or the vessel's master to the port director within 24 hours (excluding
Saturday, Sunday, and holidays) after EACH SUBSEQUENT ARRIVAL of the vessel at a Bureau of Customs and Border Protection port
from a fishing voyage, and that an accounting shall be made at the time of such presentation of the disposition of the articles withdrawn
until the port director is satisfied that all vessel supplies have been consumed on board or landed under CBP supervision, there upon the
port director will collect this form for final disposition;
(2) that any such withdrawn article remaining on board while the vessel is in port shall be safeguarded in the manner and to such extent
as the port director for the port or place of arrival shall deem necessary; and
(3) that failure to comply with the above conditions shall subject the master and/or owner to penalties and/or seizure of the vessel.
14. PORT

15. DATE

16. ENTRY/WITHDRAWAL NO.

17. SIGNATURE OF CBP OFFICER

X
MASTER'S REPORT OF ARRIVAL AND CERTIFICATION
18. ARRIVED AT (PORT)

19. DATE AND TIME OF ARRIVAL

20. NO. OF UNUSED QUANTITIES (IF ANY)

21. I CERTIFY THAT (CHECK APPROPRIATE BOX)
UNUSED QUANTITIES REMAIN ON BOARD AND ARE ADEQUATELY SECURED
ALL CONSUMED AS SUPPLIES ON VESSEL PRIOR TO ITS ARRIVAL
22. SIGNATURE OF MASTER

X
23. PORT

24. DATE AND TIME REPORT RECEIVED 25. SIGNATURE OF CBP OFFICER

X
FURTHER REPORTS TO BE ENDORSED ON REVERSE, AS NEEDED.

Editions prior to 11/96 are obsolete.

CBP Form 5125 (11/96)

MASTER'S REPORT OF ARRIVAL AND CERTIFICATION
18. ARRIVED AT (PORT)

19. DATE AND TIME OF ARRIVAL

20. NO. OF UNUSED QUANTITIES (IF ANY)

21. I CERTIFY THAT (CHECK APPROPRIATE BOX)
UNUSED QUANTITIES REMAIN ON BOARD AND ARE ADEQUATELY SECURED
ALL CONSUMED AS SUPPLIES ON VESSEL PRIOR TO ITS ARRIVAL
22. SIGNATURE OF MASTER

X
23. PORT

24. DATE AND TIME REPORT RECEIVED 25. SIGNATURE OF CBP OFFICER

X
MASTER'S REPORT OF ARRIVAL AND CERTIFICATION
18. ARRIVED AT (PORT)

19. DATE AND TIME OF ARRIVAL

20. NO. OF UNUSED QUANTITIES (IF ANY)

21. I CERTIFY THAT (CHECK APPROPRIATE BOX)
UNUSED QUANTITIES REMAIN ON BOARD AND ARE ADEQUATELY SECURED
ALL CONSUMED AS SUPPLIES ON VESSEL PRIOR TO ITS ARRIVAL
22. SIGNATURE OF MASTER

X
23. PORT

24. DATE AND TIME REPORT RECEIVED 25. SIGNATURE OF CBP OFFICER

X
MASTER'S REPORT OF ARRIVAL AND CERTIFICATION
18. ARRIVED AT (PORT)

19. DATE AND TIME OF ARRIVAL

20. NO. OF UNUSED QUANTITIES (IF ANY)

21. I CERTIFY THAT (CHECK APPROPRIATE BOX)
UNUSED QUANTITIES REMAIN ON BOARD AND ARE ADEQUATELY SECURED
ALL CONSUMED AS SUPPLIES ON VESSEL PRIOR TO ITS ARRIVAL
22. SIGNATURE OF MASTER

X
23. PORT

24. DATE AND TIME REPORT RECEIVED 25. SIGNATURE OF CBP OFFICER

X
MASTER'S REPORT OF ARRIVAL AND CERTIFICATION
18. ARRIVED AT (PORT)

19. DATE AND TIME OF ARRIVAL

20. NO. OF UNUSED QUANTITIES (IF ANY)

21. I CERTIFY THAT (CHECK APPROPRIATE BOX)
UNUSED QUANTITIES REMAIN ON BOARD AND ARE ADEQUATELY SECURED
ALL CONSUMED AS SUPPLIES ON VESSEL PRIOR TO ITS ARRIVAL
22. SIGNATURE OF MASTER

X
23. PORT

24. DATE AND TIME REPORT RECEIVED 25. SIGNATURE OF CBP OFFICER

X
PAPERWORK REDUCTION ACT NOTICE: The Paperwork Reduction Act says we must tell you why we are collecting this
information, how we will use it, and whether you have to give it to us. We ask for this information to carry out the Bureau of
Customs and Border Protection laws of the United States. This form is used by the masters of fishing vessels and brokers to
use for the conditionally free withdrawal of supplies to be used on the vessel during the voyage. The use of this form is
required to obtain or retain a benefit.
Statement Required by 5 CFR 1320.21: The estimated average burden associated with this collection of information is 5
minutes per respondent or recordkeeper depending on individual circumstances. Comments concerning the accuracy of this
burden estimate and suggestions for reducing this burden should be directed to Bureau of Customs and Border Protection,
Information Services Branch, Washington, DC 20229, and to the Office of Management and Budget, Paperwork Reduction
Project (1651-0092), Washington, DC 20503.
CBP Form 5125 (11/96)

OMB No. 1651-0092
Exp. 04/30/2009

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection

APPLICATION FOR WITHDRAWAL OF BONDED STORES
FOR FISHING VESSEL AND CERTIFICATE OF USE CONTINUATION SHEET
19 U.S.C. 1309, 1317; 19 CFR 10.59, 10.65; 27 CFR 290; CD 099-3260-050
10a. NAMES (CREW MEMBER)

10b. ADDRESSES

10c. SOCIAL SECURITY NUMBERS

CBP Form 5125 (11/96)