Ministry of Finance				Declaration on Import     �
of the Czech Republic				                         Export	 �
of cash and travellers cheques in the total amount exceeding 200 000,- Czech crowns or  foreign equivalent, gold coins and gold bullions ( Act No. 219/95 Sb. and Order No.261/95 Coll. of Laws).
I. Importing/exporting person
1. Family name | | | | | | | | | | | | | | | | | | | | | | | | | |
2. First name | | | | | | | | | | | | | | | | | | | | | | | | | |
| day | | | 4. Place of birth | | | | | | | | | | | | | |
3. Date of birth | month | | | 5. Passport number | | | | | | | | | | | | | |
| years | | | 6. Country of issue | | | | | | | | | | | | | |
II. Owner of imported/exported items (if different from I.)
7. Full name | | | | | | | | | | | | | | | | | | | | | | | | | |
8. Address | | | | | | | | | | | | | | | | | | | | | | | | | |

III. I am importing/exporting | Currency | Amount | | IV. Purpose of import/export
Czech crowns in cash | Kč | | | Personal | �
Foreign currency in cash | | | | Business | �
| | | | Other                           �
| | | | Transit (only for import)  yes    �         no    �
Travellers cheques in Kč or | | | | | | | | |
in foreign currency | | | |
Gold bullions | number of b. | | total weight | | | Personal date stamp of the
Gold coins | number of pieces | | | | customs officer:
I declare herewith that the data as given by me in this form are correct, which I confirm by my signature.
Date:				Signature: