D LIST OF ARTICLES (1) ITEM NUMBER CHECKED IN PART IV, A., B., C. (2) DESCRIPTION OF MERCHANDISE (3) VALUE OF COST OF REPAIRS (4) FOREIGN MERCHANDISE TAKEN ABROAD THIS TRIP: State when, in the U.S. the foreign merchandise was acquired or Mien and where if was prevfoutiy declared to tSP. REMStar Sleep Apnea Machine $729.00 Purchased in the US and took on trip to USVI, forgot to pack when we left island. Need in the US to sleep. ..19. VO --7v - rAL VALI4C-4I PART V - CARRIER'S CERTIFICATE AND RELEASE ORDER The undersigned carnet, to whom of upon whose order the articles described in PART I. B.. must be released. hereby certifies that the person manned in NMI. 1.. is the owner or consignee of such articles within the purview of section 484(h), Tariff Ad of 1930. In accordance with provisions of section 484(h). Tariff Ad of 1930. authority is hereby given to release the articles to such consignee. 1 NAME OF CARRIER 2. SIGNATURE OF AGENT (Print and sign) Date PART VI — CERTIFICATION TO BE COMPLETED BY ALL PERSONS SEEKING FREE ENTRY I. the undersigned. certify that the declaration a co--ect and complete. 1. 'X' One CBP Form 3299 (10/O9) defined as Nperson wfa has 141 19. 1 1 32. 141.33). PART VII CBP USE ONLY (inspected and Released) 1. SIGNATURE OF CBP OFFICIAL EFTA00314121