OMB Control Number:1651-0021; Expiration Date: 11/30/2020

U.S. Customs and Border Protection 1. Crew Member's Article No.

CREW MEMBER'S DECLARATION Nr A0000000

19 CFR 4.7, 4.7a, 4.81, 122.83, 122.84, 148.61-67
2. Carrier (Vessel Flag, Name) VH028 3. Date of Arrival 4 . Port of Arrival: MIA
06/08/2021
5 .Crew Member's Name Blair Romero Diaz 6 . Rank TCP 7.drfr
Date of Birth INSTRUCTIONS
04/06/1997 List all articles obtained abroad and prices paid or fair
value if not purchased. Include serial number with all
8 . Address: 11800 NW 101, Florida articles subject to registration such as cameras, radios,
etc.
9 . Answer Each Question :
List articles to remain on board separately from those
A. Are you carrying any fruits, B. Have you been on a C. Are you carrying over $10,000 in monetary articles to be landed in the United States.
plants, meats, other plant or farm or ranch outside instruments such as coin, currency, traveler's
animal products, birds, snails, the U.S.A. in the last checks, money orders, or negotiable List separately articles intended for sale, barter,
or other live organisms of any kind? 30 days? exchange, or carried by you as an accommodation for
instruments in bearer form? (If yes, you must
someone else.
file a report on FinCen 105)
Yes X No Yes X No Yes X No See additional instructions and information on reverse.

I. To be filled in by Crew Member II. For CBP Officer's Use

Cost or Value of
Quantity and Description of Goods Tariff Description Value Rate Duty
Gifts, etc.

I certify that the above statement is a just, true and c omplete account of all articles of foreign origin for which written
declaration and entry are required when landed in th e United States (defined on reverse side) and I also certify that this TOTAL
statement is a just, true, and complete declaration of all such articles which I am landing in the United States.
10 . CBP Officer Accepting Entry 11 . Signature of Crew Member 12 . Date 06/08/2021
BLAIR ROMERO D

RECEIPT FOR DUTY AND RELEASE SLIP Port Crew Member's Article No.
To be filled in by Crew Member
Name Carrier
Nr A0000000
Repeat List of Articles to Be Landed (include serial numbers when appropriate) For CBP Officer's Use
Date Duty $

Articles listed at left have been examined and passed

Pieces of Baggage Released:

of U.S. Customs and Border Protection

The CBP officer accepting the declaration and entry shall draw lines through unused spaces on receipt with ink.
Notice: Liquidation of amount of duties and taxes, if any, due on this entry is effective on date of payment of this amount (Section 159.10, C.R.) For
importer's right to protest or Government's right to re-determine this amount, see section 514 Tariff Act of 1930 as amended.
CBP Form 5129 (12/18) Page 1 of 2
INSTRUCTIONS FOR USE
1. This declaration must be legibly prepared using pen, typewriter, or other permanent method. This declaration is required for all articles which are to be landed by a
crew member, including any person traveling on board a vessel, vehicle, or aircraft engaged in international traffic who is returning from a trip on which the person was
employed as a crew member.

2. Include serial number with all articles subject to registration, such as cameras, radios, etc. List articles to remain on board separately from those articles to be
landed in the United States. List separately articles intended for sale, barter, exchange, or carried by you as an accommodation for someone else.

3. All articles acquired abroad by the particular officer or crew member shall be declared on the declaration, with the exception of articles exclusively for use on the
voyage which include only necessary clothing, toiletries, and purely personal effects, and not to exceed 1 open (seal broken) liter container of alcoholic beverages, and 50
cigars, or
300 cigarettes, or 2 kilos of smoking tobacco, or a proportionate amount of each, and articles which have been previously cleared through Bureau of Customs and Border
Protection and described in a proper CBP receipt release form.

4. Articles in the possession of and exclusively for use by a crew member during the voyage, such as necessary clothing, toiletries, and purely personal effects, may be
brought ashore by the crew member on temporary shore or ground leave for use while in a port without a written declaration and entry and without payment of duty or
internal revenue tax ONLY if the Port Director of CBP for the port is satisfied that the articles so landed are necessary and appropriate for the crew member's
accommodation while on temporary shore or ground leave; that they will be devoted solely to the crew member's bona fide personal use; that the quantities are reasonable,
depending upon the circumstances of each particular case; and that, in the case of tobacco products and alcoholic beverages, the container shall have been opened and
the total quantity brought ashore while the vessel is in port shall not exceed 50 cigars, 300 cigarettes, or 2 kilos of smoking tobacco, or a proportionate amount of each, and
1 liter of alcoholic beverages. In the case of articles possessing substantial commercial value, such as cameras, watches, razors, and other articles not consumed through
use, the CBP officer concerned, before passing the articles free of duty, shall be assured beyond doubt that the article is brought ashore is for the actual bona fide personal
use of the crew member while on shore or ground leave and is to be returned to the vessel or aircraft.

5. In the column headed "Cost, Or Value of Gifts, Etc.", state in United States dollars the price actually paid for the articles, or fair value if not acquired by purchase, such as a
gift.

6. If additional space is needed to list all articles in column headed "Quantity and Description of Goods", include them in another declaration form obtained from purser. Do not
alter the preprinted serial number on the declaration. (If more than one form is needed by a crew member to list articles, all serial numbers of the forms used shall be noted
opposite the crew members name on the Crew's Effects Declaration, CBP Form 1304, or the Crew List, Customs and Immigration Form I-418).

7. If insufficient space on "Receipt for Duty and Release Slip" (lower perforated stub) to repeat the listing of all articles to be landed in the United States listed in the column
headed "Quantity and Description of Goods", continue on reverse side of stub.

8. This form may be printed by private parties (see footnote) as a 2-part or 3-part set for use as both a vessel's or aircraft's crew purchase manifest and the entry record for
articles landed in the United States, when the vessel or aircraft is to clear directly foreign from the first port of arrival.

WARNING-PENALTIES
The transportation of currency or monetary instruments, regardless of the amount, is legal, however, if you take out or bring into (or attempt to take out of or bring into)
X
the United States more than $10,000 (U.S. or foreign equivalent, or a combination of the two) in coin, currency, travelers checks or bearer instruments such as
money orders, checks, stocks or bonds, you are required by law to file a report on FinCEN Form 105 (formerly Customs Form 4790). If you have someone else
carry the currency or instruments for you, you must also file the report. FAILURE TO FILE THE REQUIRED REPORT OR FALSE STATEMENTS ON THE REPORT
MAY LEAD TO SEIZURE OF THE CURRENCY OR INSTRUMENTS AND TO CIVIL PENALTIES AND/OR CRIMINAL PROSECUTION.
AXclaim for exemption from duty on an article on the false ground that it is not intended for sale and acquired or carried by the declarant as an accommodation for
others will subject the articles to forfeiture.
Any
X article which is required to be manifested and which is not manifested is subject to forfeiture and the master of the vessel is subject to a penalty equal to the
forfeiture value (sec. 584, Tariff Act, 1930, as amended). If any article requiring a declaration and entry when brought into the United States is landed without
being covered by a release slip or other permit to unlade from the Port Director, Bureau of Customs and Border Protection, the article is subject to forfeiture, the vessel
master and any other person associated with the unauthorized removal are subject to penalties equal to the forfeiture value, and if valued at $500 or over, the vessel
itself is subject to forfeiture (sect. 453, Tariff Act, 1930).

This form may be printed by private parties, Blocks of serial numbers to be used on such forms will be furnished upon written request to the CBP,
Information Services Division, Forms Manager, Washington, DC 20229. Requests should state the quantity of serial numbers needed.

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 1651-0021. The
estimated average time to complete this application is 10 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, 799 9 th Street, NW., Washington DC 20229.

CBP Form 5129 (12/18) Page 2 of 2