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.
Canada Border Services Agency
Department of Homeland Security
U.S. Customs and Border Protection
Prepare in quadruplicate
- Carrier in transit through Canada / Carrier in transit through United States
- State/Province licence plate no.
- Port of departure
- Port of re-entry (To be entered by Customs Officer at port of entry.)
- Canada permit no.
- CBSA bond no.
- Name of importing carrier (print or type)
- Name of operator or agent of carrier (print or type)
- Port and date of arrival
- CBSA seal numbers
- Initials of CBSA officer
- Port and date of exit
- Seals intact (Yes/No) (If "no", report on reverse)
- Other irregularity: (Yes/No) (If "yes", report on reverse)
- Initials of customs officer
- Waybill numbers
- No. of packages
- Value (Value to be shown only for goods transiting the United States; If estimated, so state.)
- I certify that I have received from customs at the port of arrival all goods described in the waybills listed in this manifest, which will be transported under bond and delivered to customs at the ports of exit and re-entry; that this manifest and related waybills contain a true account of all the goods on board the vehicle; that any discrepancy, error, or omission in this account, or any irregularity in the transit movement of this shipment will be immediately reported to customs.
- Signature of operator or agent of carrier
Report of irregularity
- This report covers
- Other irregularity
- Description of merchandise (obtain from waybill or other document accompanying shipment)
- Quantity manifested
- Quantity delivered at port of exit
- Quantity short
- Value of merchandise not delivered to port of exit
- Remarks (Show the number of the freight waybill under which the shipment was made; condition of seals; condition of vehicle; condition and marks and numbers of particular containers in which shortage occurred, or marks and numbers of missing pakages; when and by whom the shortage or other irregularity was noted; any other information about the circumstances surrounding the irregularity which may assist the port of arrival to determine the carrier's liability.)
- Signature of customs officer
This form may be printed by private parties provided that the supply printed conforms to this official form in size, wording, arrangement, and quality and colour of paper. For sale by collectors of customs.
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