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.
- Chief officer of CBSA
- CBSA office
- Date stamp
The goods described herein imported from (Country from which imported direct) via (1) appear to have been damaged between the time of direct shipment to Canada and the time of release from CBSA, and we hereby request that the goods be examined and the amount of damage be ascertained.
- Marks and numbers
- Number of packages
- Description of goods
- Cargo control document number
- Accounting document number
Dated at (place) this (date) day of (month) year (year)
- Name of importer/owner
- Signature of importer or authorized agent
Having received the importer's/owner's advice of damage on the (date) day of (month) year (year) I examined the (2) on the (date) day of (month) year (year) and found that the damage consisted of (Breakage, crushing, leakage, etc).
- Value for duty of goods in undamaged condition as shown on the original customs invoice $
- Amount of damage reported $
- Signature and badge number of border services officer
Instructions for completion of form
- (1) CBSA office and mode of transport.
- (2) Name of goods, such as "electric motor," "carrots," "china tableware," etc., should be written. General terms such as "machinery," "vegetables," "dishes," etc., will not be accepted.
- Date modified: