A link to the Portable Document Format (PDF) of this form is provided below. The content of the form is duplicated in HTML following the PDF link.
Protected A when completed
Privacy Act Statement
The information you provide in this document is collected under the authority of the Customs Act - Section 12 for the purpose of determining the admissibility, duty and tax treatment of the goods you are importing. The information may be disclosed to Air Carrier agents and baggage handling companies for the purposes of presenting your goods for examination by the Canada Border Services Agency (CBSA).
Failure to complete this form may result in punitive action including seizure of your goods. Individuals have the right of access to, the protection and correction of their personal information under the Privacy Act - Section 12. The information collected is described under the Personal Information Bank Delayed Baggage Report CBSA PPU 1109 which is detailed at www.infosource.gc.ca.
To be completed by carrier agent
- Name of carrier
- Missing baggage report no. (if applicable)
To be completed by traveller
- Residential status
- Resident of Canada
- Non-resident of Canada
- Address in Canada
- Postal Code
- Tel. No.
- Home address (if different from above)
- Date of birth (YYYY-MM-DD)
- Where are you arriving from? (Country)
- How long have you been absent from Canada or how long will you be stayingin Canada?
- Missing baggages tag numbers?
- Do the missing bags contain any of the following?
- Alcohol (Yes/No)
- Tobacco (Yes/No)
- Firearms or other weapons (e.g. switchblades, Mace or pepper spray) (Yes/No)
- Commercial goods, whether or not for resale (e.g. samples, tools, equipment) (Yes/No)
- Meat, fish, seafood, eggs, dairy products, fruits, vegetables, seeds, nuts, plants, flowers, wood, animals, birds, insects, and any parts, products or by-products of any of the foregoing (Yes/No)
- Currency and/or monetary instruments totalling CAN$10,000 or more per person (Yes/No)
Returning Residents Only
- What is the total value of all the goods you are bringing into Canada which were declared as having been purchased, received or acquired in any manner while outside Canada, including Duty Free shops purchases prior to departure from Canada or abroad? (Value)
- To the best of your knowledge, what is the total value of the above goods that are contained in the missing bags? (Value)
- Do the missing bags contain any gifts to residents of Canada which exceed CAN$60 in value per item or any other goods which will be left in Canada? (Yes/No) (Value)
I certify that the information given above is true and complete and I authorize the carrier mentioned above to open my baggage on my behalf for customs examination.
- Signature of traveller
- Date (YYYY-MM-DD)
- Date modified: