OMB No. 1515-0068

United States Customs Service

1. Date of Request

2. Date of Entry and Importation

4. Carrier

3. Manufacturer/Seller/Shipper

5. Entry No.

5b. Invoice No.

5a. Invoice Description of Merchandise

6. HTSUS Item No.

7. Country of Origin/Exportation

8. Customs Broker and Reference or File No.

10. FROM:

9. TO:

11a. Port

11b. Date Information
        Furnished

Production of Documents and/or Information Required by Law: If you have provided the information requested on this form to U.S. Customs at other ports, please indicate the port of entry to which it was supplied, and furnish a copy of your reply to this office, if possible.

REQUEST FOR INFORMATION

19 CFR 151.11

Any data typed after screen scrolls will not print.

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

United States Customs Service Request for Information.
19 C F R 151.11 O M B Number 15 15-00 68. Any data typed after screen scrolls will not print. Production of Documents and/or Information Required by Law: If you have provided the information requested on this form to U S Customs at other ports, please indicate the port of entry to which it was supplied, and furnish a copy of your reply to this office, if possible.

Customs Form 28 (02/02)

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