Annex
to the Resolution of the Cabinet
of Ministers of Ukraine 
from February, 27, 2019 №203
	Form of declaration of transboundary movement by private persons of currency values

Read the notes on the reverse side before filling out the form

FILL WITH UPPERCASE LETTERS / MARK WHAT YOU NEED	UA	
		А.  Number of declaration	
1. YOU ARE:	     Entering the country	        Leaving the country	
				
2. Personal Data	     Male         Ж  Female	Place of issue		
Surname		Date of issue	D	D	М	М	Y	Y	Y	Y		
Given Names		ID-code		
Nationality		Registration Address
(street, building number, apartment)		
Date of Birth	D	D	М	М	Y	Y	Y	Y				
Place of Birth		City 		
Document	    Passport  book
    Passport card
    Other	ZIP Code / Code		
Passport number / other document		Country		
				
3. Owner - YOU	     Yes (go to the step 4)	No, owner is:
(provide owner information)	        Legal entity  	
			
        Private individuals	
Legal entity name		Address
(street, building number, apartment)	
	
Registration number / VAT identification number		City		
Last Name 		ZIP Code / Code		
Name		Country		
				
4. Information about currency values   Amount/Weight (use numerals and words)                                      Currency/Metal/Name	
Banknotes, coins			

			
Other			

5. The origin and destination of currency values	
The origin		
The destination		
You are the recipient 	      Yes (go to the step 6)	No, the recipient is: 
(information about the owner)	        Legal entity  	
			
        Private individuals	
Legal entity  		Address
(street, building number, apartment)		
Registration number / VAT identification number		City		
Last Name 		ZIP Code / Code		
Name		Country		
				
6. Information about the vehicle	
Type of transport	     Air              Water                            Automobile transport          Railway                      Other	
Transport Company		Reference number		
Country of departure		Date of departure	D	D	М	М	Y	Y	Y	Y		
Country of transit		Date of transit	D	D	М	М	Y	Y	Y	Y		
Country of destination		Date of destination	D	D	М	М	Y	Y	Y	Y		
				
7. Signature of the declarant
I provide that all information I have filled is accurate. I understand that invalid, inaccurate or incomplete information will entail liability accordance the law.	В. Signature and seal of the competent authority	С. For official notes
	
Date	D	D	М	М	Y	Y	Y	Y			

The reverse side
OVERVIEW:
	The declaration is filled personally by a citizen who has reached the age of 16 years, or a person authorized by him.
	Declaration of the currency values by individuals for their cross-border movement fill according to the Article 8 of the Law of Ukraine dated June, 21, 2018 № 2473-VIII "On currency and foreign currency transactions" and Articles 371, 374 of the Customs Code of Ukraine.
	You must fill out this form if:
-carry out the cross-border movement of the currency of Ukraine, foreign currency and bank metals in an amount equal to or exceed the equivalent of 10,000 euros;
-make export outside of the customs territory of Ukraine payment documents and securities (stocks, bonds, coupons them, exchange (draft), debt receipts, letters of credit, checks, bank orders, certificates of deposit and other financial and banking documents), which are denominated in the currency of Ukraine, in foreign currency or bank metals, the total invoice value of which exceeds the equivalent of 10,000 euros;
-make entry into the customs territory of Ukraine payment documents and securities (stocks, bonds, coupons them, exchange (draft), debt receipts, letters of credit, checks, bank orders, certificates of deposit and other financial and banking documents), which are denominated in the currency of Ukraine, in foreign currency or bank metals, the total invoice value of them exceed the equivalent of 1,000 euros in carry-on baggage and / or accompanied baggage through check points across the state border of Ukraine, opened for air traffic, and the total invoice value of them exceed the equivalent of 500 euros and / or total weight of them exceed 50 kg in hand luggage and / or accompanied baggage through other than open to air traffic, checkpoints across the state border of Ukraine.
	Providing invalid, inaccurate or incomplete information in the declaration is entailing liability accordance to the law.
ORDER OF FILLING
	The declaration is filling in one copy. Information that is not fitted on one form of the declaration will be indicated by a citizen or authorized person on separate forms of the declaration (additional sheets). In this case, in the upper right corner of the front side of each additional sheet of declaration, the citizen or authorized person takes the entry "Additional sheet". Filled additional sheets are an integral part of the declaration.
	The information will be indicated by a citizen or authorized person in Ukrainian, the official language of customs unions, a member of which is Ukraine, or another foreign language of international communication.
	All white fields are filling by the declarant in big letters with dark ink; gray fields that are marked with Latin letters A, B, C, are filling by an official of the customs.
	The declaration is not accepted for customs clearance by an official of the customs in case of filling out a declaration, the form of which differs from the established, and in violation of the requirements of the order of filling;
	Alongside with the filled declaration for customs control and customs clearance of goods, a citizen or an authorized person will submit the following documents:
-documents that certify a person and confirm the country of permanent residence of a citizen or an authorized person;
-documents that confirm the withdrawal of cash from their own accounts with banks and the acquisition by a person of bank metals in banks and / or the National Bank specified in paragraph 18 of the Resolution of the Board of the National Bank of Ukraine from January 2, 2019, No. 5 "On Approval of the Regulations on Protection Measures and Determining the Procedure for the Implementation of Certain Foreign Currency Transactions".
1. Entry Ukraine /Leaving Ukraine: put in the field for indicating the direction of movement
X-shaped mark in the desired frame.
2. Personal data: filled in by submitting documented data about an individual.
3. Personal information about the owner: if you are not the owner of currency values, please indicate the owner's data. The owner may be a natural or legal person. Mark the X-shaped mark in the desired frame and enter the data.
4. Information on currency values: indicate the exact amount of each currency in figures and words, precious metals - weight in grams and the value in euros of each precious metal in figures and words, payment documents and securities - the name and value of words and numbers. While declaring the information states in this format, for example: 10 500 (TEN THOUSAND FIVE HUNDRED) EUR 18,300 (EIGHTEEN THOUSAND THREE HUNDRED US DOLLARS), 500 g (FIVE HUNDRED GRAMS) of gold, 17,000 (SEVENTEEN THOUSAND) EUROS, BILL.
5. Origin and purpose of the use of currency values: indicate the source of obtaining currency values, for example: savings, inheritance, sale of property, etc. Briefly explain the purpose of the use, for example: purchase of property, investment, etc. The intended recipient may be a natural or legal person. Mark the X-shaped mark in the desired frame and enter the data.
6. Vehicle Information: Select the X-mark:
"Air" / - when entering / leaving by air transport. The “Reference Number” column indicates the flight number or registration number of the board.
“Water”/  – when entering / leaving by the sea or river transport. The “Reference Number” column indicates the name of the vessel.
“Automobile transport”/    — when entering / leaving by road transport. The “Reference Number” column indicates the registration number of the vehicle.
“Railway”/ — when entering / leaving by rail transport. The “Reference Number” column indicates the number of the train.
“Other” – when going by other type of transport (for example, on a bicycle, on foot, etc.).
7. Signature of the declarant: sign the declaration and indicate the date of filling.

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