U.S. Department of State
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REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE
Name of Embassy, Legation, or International Organization (Includes U.N.)
To the Secretary of State - Attention: Office of Foreign Missions
It is requested that the necessary arrangements be made for the appropriate authorities to admit free of duty the merchandise described below. This
merchandise is intended for the personal and/or official use of the person(s) or foreign government noted based on reciprocity or, for representatives of
international organizations, or others herein designated, based on privileges under the authority specified on the form.
Port of Clearance
Official (Explain Below)
Personal Official and Personal
Customs Entry or Manifest Number Air Waybill or Bill of Lading Number
Total Weight lbs. or kg. Mail Entry Number
Description of Merchandise - Including warehouse or Catalogue Number (if withdrawn from a customs bonded warehouse or foreign trade zone).
If vehicle, include Vehicle Identification Number, Make, Model, and Year.
Signature of Authorized Representative of International Organization (Includes U.N.) Date (mm-dd-yyyy)
Embassy or Consulate Seal
U.S. Department of State
USUN U.S. Customs Authorization
OMB Approval No. 1405-0105
Estimated burden: 15 Minutes
See Page 7
Date (mm-dd-yyyy) Free Entry Requested
Name (First, Middle, Last)
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations
of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions Act of 1982
(22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to adjudicate requests for customs clearance of merchandise.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of customs
clearance of merchandise.
PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.
You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the
accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW, Washington,
DS-1504 Page 7 of 7
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