Form 7501 Entry Summary

DEPARTMENT OF HOMELAND SECURITY

1. Filer Code/Entry No.

U.S. Customs and Border Protection
ENTRY SUMMARY

Form Approved OMB No. 1651-0022
EXP. 03-31-2012

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
27.
Line
No.

State

Zip

City
A. Entered Value
B. CHGS
C. Relationship

35. Total Entered Value

$
36. DECLARATION OF IMPORTER OF RECORD (OWNER
OR PURCHASER) OR AUTHORIZED AGENT
Importer of record and that the actual owner,

or purchaser or agent thereof. I further declare that the merchandise

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

CBP USE ONLY

Total Other Fees

purchaser, or consignee for CBP purposes is as shown above, OR

State
32.

$

I declare that I am the

24. Reference No.

26. Importer of Record Name and Address

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

Other Fee Summary for Block 39

20. U.S. Port of Unlading

Zip
34.
Duty and I.R. Tax
Dollars

Cents

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 (06/09)

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
EXP. 03-31-2012

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 (06/09)

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
EXP. 03-31-2012

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 (06/09)

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
EXP. 03-31-2012

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 (06/09)

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
EXP. 03-31-2012

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 (06/09)