Form No. 1.

Port of

SCHEDULE (B.) referred to in the foregoing Act.

Official Number.
Number of Register.
Date of Registry.
If Sailing Vessel
or Steamer.

REPORT.

British or Foreign;

Number of Crew.

Ship's
Name.

if British, Port of Registry;

Tonnage.

if Foreign, Country to which
she belongs.

British Foreign
Seamen. Seamen.

Name of Master,
and whether a
British or
Foreign Subject.

Here state the particulars according to the above headings.

Total

Port or

Place from

whence arrived.

Here state the particulars according to the above headings, or if in Ballast, state "in Ballast only." If any wreck

I declare that the above is a just report of my ship and of her lading, and that the particulars therein inserted are true to the best of my knowledge, and that I have not broken

bulk or delivered any goods out of my said ship since her departure from the last foreign place of loading, (except, if so, at

, stating where).

Whether Prime or Post, and if Post date of Prime Entry

Here state the particulars of the goods according to the above headings.

Marks.

Numbers.

Number of Packages, quantity, description, and value of Goods,
in accordance with the requirements of the
Official Import List.

Here state the particulars of the goods according to the above headings.

I,

State the particulars according to the respective headings given above.

the importer (or agent to the importer) of the goods above mentioned, do hereby declare (if importer) that I have not, or (if agent) that, to the best of my knowledge, he has not received sufficient invoice, bill of lading, or other advice from whence the quality, quantity, or value of the goods above mentioned can be ascertained. Dated this 187 •

day of

Here state the particulars of the goods according to the above headings.

I enter the above goods as free of duty, and declare the above particulars to be true.

Marks.

Numbers.

Description of
Packages.

Quantity, Quality, and Value, and
Description of Goods.

Total Number of
Packages.

Here state the quantity and description in words at length of any goods in respect of which drawback is claimed.

(Signed)

adding "exporter" or "agent," as the case may be.

SPECIFICATION for Foreign Goods free of duty or on which all duties have been paid.

Dated

I declare that the particulars set forth above are correctly stated.