Form CBP Form 6043 CBP Form 6043 Delivery Ticket

OMB APPROVAL NO. 1651-0081
EXPIRES: 09-30-2019
ESTIMATED BURDEN: 20 MIN.

DEPARTMENT OF HOMELAND SECURITY

U.S. Customs and Border Protection
DELIVERY TICKET

19 CFR 4.34, 4.37, 19.9; 19 USC 1551a, 1565
PORT
TRANSFER

ENTRY NUMBER (IT, G.O., Detention, SZ, Other, Describe)

CARTAGE

RELEASE

GOODS DELIVERED TO

DATE OF ENTRY

GOODS DELIVERED FROM (Pier, Station, Airport, etc.)
DATE OF ARRIVAL

NAME AND ADDRESS OF CONSIGNEE

AIR WAYBILL OR BILL OF LADING NO.
NAME OF IMPORTING CARRIER (If Airline, Give Airline and Flt. No.)
LIEN NO.

DATE OF LIEN

LIEN SATISFIED (19 USC 1564)
DATE
ENTRY
MARKS AND NUMBERS
CONT. NUMBER, PIECE COUNT

TOTAL NO. OF PACKAGES / UNITS

LIEN FILED BY

SALE

DESCRIPTION OF MERCHANDISE

DESTROYED

CONDITION, WEIGHTS, ETC.

SIGNATURE OF CONSIGNEE

Delivered in good condition except as noted

Received in good condition except as noted

QUANTITY DISCREPANCIES NOTE HERE:
VEHICLE LICENSE PLATE NUMBER

CUSTODIAL BOND NUMBER OF DELIVERING PARTY (19 CFR 113.63)

C.H. LICENSE NUMBER

TRUCK NUMBER

COMPANY NAME

SIGNATURE OF CARTMAN/ LIGHTERMAN/ COMMON CARRIER
(Sign in ink)
DELIVERING CBP OFFICER
DELIVERING PROPRIETOR

DATE

TIME

RECEIVING CBP OFFICER

DATE

TIME

RECEIVING PROPRIETOR

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1651-0081. The estimated
average time to complete this application is 20 minutes. If you have any comments regarding the burden estimate you can write to U.S. Customs and Border
Protection, Office of Regulations and Rulings, 10th Floor, 90 K Street NE, Washington DC 20229-1177.
CBP Form 6043 (3/19)

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