Example of Where Information will be on Form 7501

Form Approved OMB No. 1651-0022

DEPARTMENT OF HOMELAND SECURITY

1. Filer Code/Entry No.

U.S. Customs and Border Protection
ENTRY SUMMARY

2. Entry Type

3. Summary Date

4. Surety No. 5. Bond Type 6. Port Code

7. Entry Date

8. Importing Carrier

9. Mode of Transport

10. Country of Origin

11. Import Date

12. B/L or AWB No.

13. Manufacturer ID

14. Exporting Country

15. Export Date

16. I.T. No.

17. I.T. Date

21. Location of Goods/G.O. No.

18. Missing Docs 19. Foreign Port of Lading

22. Consignee No.

23. Importer No.

25. Ultimate Consignee Name and Address

City

Zip

City

Line
No.

28. Description of Merchandise
29.
30.
31.
A. HTSUS No.
A. Grossweight
Net Quantity in
B. ADA/CVD No.
B. Manifest Qty. HTSUS Units

01

4407.10.00.00
NNNNNNNNN

24. Reference No.

26. Importer of Record Name and Address

State

27.

20. U.S. Port of Unlading

State

A. Entered Value
B. CHGS
C. Relationship

33.
A. HTSUS Rate
B. ADA/CVD Rate
C. IRC Rate
D. Visa No.

34.
Duty and I.R. Tax

$13,295.16

0.00%

0.00%

32.

YNNNNNNNNNNNNNNN

Zip

Dollars

Cents

Estimated export
charge, if any.
Export price.
"Y" indicates
required
35. Total Entered Value
Other Fee Summary for declaration.
Block 39

CBP USE ONLY

$
Total Other Fees
$
36. DECLARATION OF IMPORTER OF RECORD (OWNER
OR PURCHASER) OR AUTHORIZED AGENT
I declare that I am the

Importer of record and that the actual owner,

purchaser, or consignee for CBP purposes is as shown above, OR
or purchaser or agent thereof. I further declare that the merchandise

TOTALS

A. LIQ CODE

B. Ascertained Duty

37. Duty

REASON CODE

C. Ascertained Tax

38. Tax

D. Ascertained Other

39. Other

E. Ascertained Total

40. Total

owner
was obtained pursuant to a purchase or agreement to purchase and that the

prices set forth in the invoices are true, OR
was not obtained pursuant to a purchase or agreement to purchase and the statements in the invoices as
to value or price are true to the best of my knowledge and belief. I also declare that the statements in the documents herein filed fully disclose to the best
of my knowledge and belief the true prices, values, quantities, rebates, drawbacks, fees, commissions, and royalties and are true and correct, and that all
goods or services provided to the seller of the merchandise either free or at reduced cost are fully disclosed.
I will immediately furnish to the appropriate CBP officer any information showing a different statement of facts.

41. DECLARANT NAME

TITLE

42. Broker/Filer Information (Name, address, phone number)

SIGNATURE

DATE

43. Broker/Importer File No.

PaperWork Reduction Act Notice

CBP Form 7501 (04/05)

DEPARTMENT OF HOMELAND SECURITY ENTRY SUMMARY CONTINUATION SHEET

U.S. Customs and Border Protection

27.
Line
No.

1. Filer Code/Entry No.

28. Description of Merchandise
29.
A. HTSUS No.
B. ADA/CVD No.

30.
A. Grossweight
B. Manifest Qty.

OMB No. 1651-0022

32.
31.

Net Quantity in
HTSUS Units

A. Entered Value
B. CHGS
C. Relationship

33.
A. HTSUS Rate
B. ADA/CVD Rate
C. IRC Rate
D. Visa No.

34.
Duty and I.R. Tax
Dollars

Cents

CBP Form 7501 (04/05)

DEPARTMENT OF HOMELAND SECURITY ENTRY SUMMARY CONTINUATION SHEET

U.S. Customs and Border Protection

27.
Line
No.

1. Filer Code/Entry No.

28. Description of Merchandise
29.
A. HTSUS No.
B. ADA/CVD No.

30.
A. Grossweight
B. Manifest Qty.

OMB No. 1651-0022

32.
31.

Net Quantity in
HTSUS Units

A. Entered Value
B. CHGS
C. Relationship

33.
A. HTSUS Rate
B. ADA/CVD Rate
C. IRC Rate
D. Visa No.

34.
Duty and I.R. Tax
Dollars

Cents

CBP Form 7501 (04/05)

DEPARTMENT OF HOMELAND SECURITY ENTRY SUMMARY CONTINUATION SHEET

U.S. Customs and Border Protection

27.
Line
No.

1. Filer Code/Entry No.

28. Description of Merchandise
29.
A. HTSUS No.
B. ADA/CVD No.

30.
A. Grossweight
B. Manifest Qty.

OMB No. 1651-0022

32.
31.

Net Quantity in
HTSUS Units

A. Entered Value
B. CHGS
C. Relationship

33.
A. HTSUS Rate
B. ADA/CVD Rate
C. IRC Rate
D. Visa No.

34.
Duty and I.R. Tax
Dollars

Cents

CBP Form 7501 (04/05)

DEPARTMENT OF HOMELAND SECURITY ENTRY SUMMARY CONTINUATION SHEET

U.S. Customs and Border Protection

27.
Line
No.

1. Filer Code/Entry No.

28. Description of Merchandise
29.
A. HTSUS No.
B. ADA/CVD No.

30.
A. Grossweight
B. Manifest Qty.

OMB No. 1651-0022

32.
31.

Net Quantity in
HTSUS Units

A. Entered Value
B. CHGS
C. Relationship

33.
A. HTSUS Rate
B. ADA/CVD Rate
C. IRC Rate
D. Visa No.

34.
Duty and I.R. Tax
Dollars

Cents

CBP Form 7501 (04/05)