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DEPARTMENT OF THE TREASURY
Attach Additional Sheets Here
Form Approved.
Read Carefully Instructions for Preparation of Invoice
O.M.B. No. 48-RO342
(THIS FORM DOES NOT REQUIRE CERTIFICATION BY A UNITED STATES CONSULAR OFFICER)
SPECIAL CUSTOMS INVOICE
U. S. CUSTOMS SERVICE
(Original only required for customs purposes)
I. THIS SECTION TO BE FILLED IN FOR EVERY SHIPMENT
1. How were goods obtained by importer? By purchase or agreement to purchase By some means other than a purchase
DO NOT INCLUDE PURCHASE AND NONPURCHASE GOODS IN SAME INVOICE. USE SEPARATE INVOICE FOR EACH
2. Place (fity and country) and, duke obguard bycapitanber 1976 3. Name of exporting carrier
4. gate PO thipGent
GOODS WERE PURCHASED OR
U. TO BE FILLERED TO BE PURCHASED
III. TO BE FILLED IN IF GOODS WERE NOT PURCHASED
1. Name and address of seller
Franses of Piccadilly, 169
1. Name and address of person from whom goods were obtained
Piccadilly, London V.1.
2. Napp ing jeddrey ]of Population "Inc ., 48
Lith Avenue 2. Name and address of consignce
ew York MY 10017 U.deh.
3. Date order accepted
29th September 1976
3. Name and address of person for whose account goods are shipped
IV. THIS SECTION TO BE FILLED IN FOR EVERY SHIPMENT
(2)
(3)
(4)
MARKS AND
INVOICE TOTALS AND
(6)
(7)
MANUFAC
CURRENT
NUMBERS ON
TURER S OR
QUANTITY AND FULL DESCRIPTION OF GOODS
SELLER'S
(State contents of each package and importer's
INVOICE
UNIT
SHOW SEPARATELY
PACKING COSTS; ALL
UNIT PRICE
FOR HOME
ONIT PRICE
SHIPPING
FOR EXPORT
PACKAGES
NUMBERS OR
numbers or symbols, if any)
PRICE OR
VALUE
CHARGES
CONSUMPTION
IN HOME
TO UNITED
SYMBOLS
EXPENSES
CURRENCY
STATES
Bale
W. J. Darby did As per invoices attached:
$3,000.90 83,000.00
$3,000.90 23,000 00
e Nutritional
fundation Inc.,
19 Fifth Ave,
The following charges are additional to invoice price:-
few York NY10017
Packing in Labour and Materials...
Including in Invoice
S.A.
IT 1057/AE
Inland Cartage.. ..
. .. .
Price
$11.50
ross wight 18kgo
Insurance premium. . . . .
mensions
ix10x9 inches
Air Freight. . ...
TO HAY OR STRAW
(8) Country of origin
As per Invoices
(9) If rate of exchange is fixed or agreed, give rate
(10) If discount is freely offered, give terms, amount, and whether
trade or cash
V. THIS SECTION TO BE FILLED IN FOR EVERY SHIPMENT
1. IF GOODS WERE PURCHASED, have you stated in section IV, column 4, the purchase price of each item in the currency in which the goods were
bought? Yes No.
2. IF THE GOODS WERE NOT PURCHASED, have you stated in section IV, column 4, the price that you would have received or would be willing
to receive now if the goods were sold in the ordinary course of trade for exportation to the United States? Yes" No."
3. What currency was used in this invoice transaction? ......
... DARAT..
4. Whether the goods were purchased or obtained by the United States importer in some other manner, have you stated in section IV, column 6:
(A) (1) The price at which you are now selling the goods or offering them for sale for home consumption, including all applicable taxes?
Yes No.
(2) Is this price freely offered to anyone who wishes to buy the goods for home consumption? Yes No.
(B) (1) Have you stated in section IV, column 7, the price at which you are now selling the goods or offering them for sale for export to the
United States and whether this price is f.o.b., c.i.f., c.&f., or whatever the fact may be? Yes No.
(2) Is this price freely offered to anyone who wishes to buy the goods for export to the United States? Yes ] No.
S. Have you listed all charges and stated whether each amount has been included in or excluded from the invoice amount? Yes [] No.
Is the inland freight included in the invoice price or value? Yes ( No. Is the price or value of the goods the same at the factory as at the
point of delivery? "Yes No. If the answer is No, have any sales been made at an ex-factory price? -Yes--No--
6. Are any rebates, drawbacks, bounties, or other grants allowed upon the exportation of the goods? " Yes xNo. If so, have all been separately
itemized? -Yes- 3-No. -.-
7. If such or similar goods are being sold or offered for sale in the home market for home consumption, what taxes are applicable and are they included
in the price shown in section IV, column 6?
Rate ...
Kind .
CUSTOMS FORM 5515 (8-21-73)
Source: https:/www.industrydocuments.ucsf.edu/docs/

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