ASG FORM TRS/CUSTOMS 205 ENTRY NO __________________

REVISED 11/20/96
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AMERICAN SAMOA GOVERNMENT
TREASURY DEPARTMENT
CUSTOMS AND EXCISE TAX DIVISION
CUSTOMS DECLARATION OF ENTRY
SHIP VOYAGE CONSIGNEE B/L NO(S) FROM ARR’D PPG
AVEIA

INVOICE VALUED EXCISE TAX AMOUNT OF

DESCRIPTION
NUMBER DECLARED RATE EXCISE TAX
8%

CUTOMS DECLARATION FEE $5.00

CREDIT MEMO ATTACHED
TOTAL EXCISE TAX $
INSPECTION FEE $
OVERTIME FEE
SCANNING FEE $
TOTAL
PAID BY CASH CHECK# RECEIPT# $

WARNING! READ THE BELOW BEFORE SIGNING THIS DECLARATION

UNDER THE PENALTY OF FALSE DECLARATION (AMERICAN SAMOA CRIMINAL CODE 46.4607).I DO HEREBY CERTIFY
THAT THIS DECLARATION, AND ALL VENDOR INVOICE(S) ATTACHED HERETO, ARE TRUE AND CORRECT. I FURTHER
CERTIFY THAT NO ITEMS, THE IMPORTATION OF WHICH ARE PROHIBITED BY AMERICAN SAMOA LAVY, ARE AMOUNG
THE CARGO CONSIGNED TO ME, AND THAT ALL DUTIABLE ITEMS HAVE BEEN LISTED. FAILURE TO DECLARE DUTIABLE
GOODS MAY RESULT IN THEIR SEIZURE.

CONSIGNEE: AVEIA INC.

BY: __________________________ DATE: _____________

DECLARED, EXMINED AND ENTERED AT

INSPECTION INFORMATION CUSTOMS HOUSE, EXCISE TAX AND

DATE: ____/_____/____ TIME: ___________ OTHER CHARGES ASSESSED AND COLLECTED.

PLACE: __________________________________
REMARKS: _______________________________ CUSTOMS OFFICER ______________________

_______________________________________ BADGE # __________ DATE: ____/____/____

_______________________________________ COMPUTER USE ONLY:

INSPECTOR: ____________________________
ENTERED BY: __________________________

BADGE # __________ DATE: ____/____/____