Port of ________________, Port Director's Office, __________________, 19____.
I, ____________________, declare that the several articles described in the annexed entry are, to the best of my knowledge and belief, the identical articles exported from the United States on the ____________ day of ____________, 19____, by __________________ (Actual shipper) address ________________, for the account of ________________, address ________________that they are returned to ________________, address ________________, for the account of ________________, address ______________ that the said articles were exported solely for temporary scientific or educational purposes and for no other use abroad than for exhibition, examination, or experimentation; that they are being returned without having been changed in condition in any manner, except by reason of their bona fide use as follows:
_______________________________
(Describe change in condition)
_______________________________
(Ultimate consignee)
19 C.F.R. §10.67