Form CBP-FORM-6043 Delivery Ticket

Form Approved OMB No. 1651-0081

DEPARTMENT OF HOMELAND SECURITY

Bureau of Customs and Border Protection
DELIVERY TICKET

PORT

ENTRY NUMBER (IT, G.O., Detention, SZ, Other, Describe)

19 CFR 4.34, 4.37, 19.9; 19 USC 1551a, 1565
TRANSFER

CARTAGE

RELEASE

GOODS DELIVERED TO

GOODS DELIVERED FROM (Pier, Station, Airport, etc.)
DATE OF ENTRY

DATE OF ARRIVAL

NAME AND ADDRESS OF CONSIGNEE

AIRWAY BILL OR BILL OF LADING NO.

NAME OF IMPORTING CARRIER (If Airline, Give Airline and Flt. No.)

LIEN NO.

DATE OF LIEN

LIEN FILED BY

LIEN SATISFIED (19 USC 1564)
DATE
ENTRY
MARKS AND NUMBERS
CONT. NUMBER, PIECE COUNT

DESCRIPTION OF MERCHANDISE

SALE

DESTROYED

CONDITION, WEIGHTS, ETC.

TOTAL NO. OF PACKAGES / UNITS SIGNATURE OF CONSIGNEE

Delivered in good condition except as noted

Received in good condition except as noted

QUANTITY DISCREPANCIES NOTE HERE:

VEHICLE LICENSE PLATE NUMBER

CUSTODIAL BOND NUMBER OF DELIVERING PARTY (19 CFR 113.63)

C.H. LICENSE NUMBER

TRUCK NUMBER

DELIVERING CBP OFFICER

DATE

DELIVERING PROPRIETOR

COMPANY NAME AND SIGNATURE OF CARTMAN/ LIGHTERMAN/
COMMON CARRIER
TIME

RECEIVING CBP OFFICER

DATE

TIME

RECEIVING PROPRIETOR

According to the Paperwork Reduction Act, no persons are required to respond to a Collection of information unless it displays a valid OMB Control Number. The valid OMB Control
Number for this information collection is 1651-0081. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

CBP Form-6043 (5-03)