MINISTÉRIO DA FAZENDA
SECRETARIA DA RECEITA FEDERAL DO BRASIL
Currency Declaration Form	
Traveler’s Identification	

Full name:	
Nationality:							                    Date of Birth:          /           /
Identification Document:

	CPF / e-CPF:							Passport:
	Other:		Description of Document:
			Number of Identification:
	
Travel Information	
Way of Transportation:
5 Waterway	                 Craft type:

5 Air  	Flight number:			 Air carrier:

5 Land	5 Line Coach	
		5 Tourism Coach
		5 Owned vehicle

		5 Others:	

Port of Entry/Departure:	

5 Entry in Brazil                       	Country of origin (Origin of trip):

					Country of provenance (Last Transit country):

5 Departure of Brazil                	Country of destination:

Purpose:	5 Tourism	5 Business	5 Moving	5 Other:

Comments:

Currency and other monetary instruments	
	Currencies	Amount	Equivalents in “Real” (R$)		

																																											

	Total in Real (R$) = 																

I declare under the penalty of law that the information contained in this form is, to the best of my knowledge and belief, true, complete and correct.

Place:_________________________  Date:___/___/______ Signature:_____________________________________

Approved by the Normative Instruction RFB no  1059/2010.  Present the original and a copy.