DECLARATION OF CARRYING OF MEANS OF PAYMENT, ETC. (For Customs)

1 Kinds and amounts or weights of means of payment, etc. to be exported (or imported) (1) Means of payment or securities ☐ Currency and Coins (amount in original currency) ☐ Checks (including T/C) ☐ Promissory notes ☐ Securities Total amount (Omit any fractional amount less than 1 million JPY(\*) or its equivalent) ¥ \* 0.1 million JPY in a case that you are bound for North Korea (2) ☐ Precious metal (limited to gold of not less than 90% purity) Total weight (Omit any fractional weight less than 1 kg)　kg

2 Place of destination or shipment ☐ Export — [Flight No. / Vessel Name: ] [Place of disembarkation: ] ☐ Import — [Flight No. / Vessel Name: ] [Place of embarkation: ]

3 Expected date of export (or import)　☐ Day of declaration　☐ Day after declaration Signature For official use only　Date of permission ## (Reverse side) Instructions

1 Check the applicable box(es) of listed means of payment.

2 Print your name clearly.

3 Enter the amount of means of payment and securities in the original currency, expressed as follows: (1) Means of payment (currency and coins, checks (including T/C) and promissory notes): face value (2) Securities (securities [T. Bonds, equity, etc.] as defined in paragraph 1, Article 2 of the Financial Instruments and Exchange Law [Law No. 25, 1948]): price or value (whichever is higher) of the following ① Current price at the day of declaration ② Book value ③ Acquisition price (3) Omit any fractional amount less than 1 million JPY(\*) or its equivalent when you enter the total amount. \* 0.1 million JPY in a case that you are bound for North Korea (4) Foreign Exchange rates as defined in Article 1 of the Regulation for Enforcement of the Customs Tariff Law (MOF Ordinance No. 16, 1969) should be used in converting foreign currencies into Japanese Yen. (5) Please use the "Others" box below if you require more space. Be advised, however, that this must also be completed in triplicate.

4 Omit any fractional weight less than 1 kg when you enter the total weight of precious metal.

5 "Day after declaration" means that your scheduled date of departure is the day after you submit this form to Customs.

6 If you have any questions, please ask a Customs official. (Others) [ Penalty ] Those who carry means of payment and securities exceeding 1 million JPY(\*) or its equivalent, or gold exceeding 1 kg on their person to export or import, must complete this declaration form and declare to Customs, which has jurisdiction over the airport or the port where they depart or enter the country, on the day of or the day before exportation or importation, according to the Article 67 of the Customs Law (Law No. 61, 1954). Those who (attempt to) export or import without declaration or with false or fraudulent declaration may be subject to a penalty for violation of the Customs Law. \* 0.1 million JPY in a case that you are bound for North Korea