Each arriving traveler or head of family must provide the following information (only ONE written declaration per family is required): 每一位入境美國的游客或一家之主必須提供以下資料 (一個家庭只須申報一份):
2. Birth date∶ Day ________ Month ________ Year ________ 〈出生日期∶ 日 ________ 月 ________ 年 ________〉:
3. Number of family members traveling with you〈與你同行的家庭成員人數〉:
4. a. U.S. street address (hotel name/destination)∶〈在美居住地址(旅館名稱/目的地〉: b. City 〈城市〉 c. State 〈州〉
5. Passport issue by (country)∶〈發照國家〉
6. Passport number∶〈護照號碼〉
7. Country of Residence∶〈居住國家〉
8. Countries visited on this trip prior to U.S. arrival∶〈此次旅游時來美國之前去過的國家〉
9. Airline/Flight No. or Vessel Name: 〈航空公司/班機號碼或船名〉:
10. The purpose of my trip is or was BUSINESS ○ YES ○NO〈此次旅程的目的主要是商務 ○ 是 ○否〉
11. I am (We are) bringing∶ 〈我(我們)攜帶〉∶ a. fruits, plants, food, or insects? 〈水果，植物，食物或昆蟲？〉 b. meats, animals, or animal/wildlife products? 〈肉類、動物或動物/野生動物制品？〉 c. disease agents, cell cultures, or snails? 〈帶病原體、細胞培養或蝸牛？〉 d. soil or have you visited a farm/ranch/pasture outside the United States? 〈土壤或你曾經去過美國境外的農場或牧場嗎？〉
12. I have (We have) been in close proximity of (such as touching or handling) livestock outside the United States?∶〈我有(我們有)靠近(如觸碰或接觸)牲畜○ 是 ○否？〉
13. I am (we are) carrying currency or monetary instruments over ,000 U.S. or the foreign equivalent. ○ YES ○NO 〈你攜帶現金或財物品，其價值超過一萬美金或相當於一萬美金的外幣嗎？ ○是 ○否〉
14. I have (We have) commercial merchandise: (article for sale, samples used for soliciting orders, or goods that are not considered personal effects)○ YES ○NO〈我(我們)有攜帶商品∶(販賣物品、商業樣品或任何不屬於個人所有的物品)○是 ○否〉
15. Residents - the total value of all good, including commercial merchandise I/We have purchased or acquired abroad, (including gifts for someone else, but not items mailed to the U.S.) and am/are bringing to the U.S. is:〈美國居民- 我們帶入美國所有物品(包含商品及禮品，但不包含郵寄入美國的物品)的種價值為∶〉
Visitors - the total value of all article that will remain in the U.S., including commercial merchandise is: 〈觀光客- 將留在美國境內的物品價值為(包含商品)∶
Read the instruction on the back of this form. Space is provided to list all the items you must declare.〈請閱本表讀背面的說明，請將須申報的物品在空格內列出〉
I HAVE READ THE IMPORTANT INFORMATION ON THE REVERSE SIDE OF THIS FORM AND HAVE MADE A TRUTHFUL DECLARATION. 〈我已閱讀過背面的說明，且已就實申報〉
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