Traveler Certification Form

Black Travelers International – Traveler Certification

(Required under 31 CFR §515, Cuban Assets Control Regulations)
Traveler Name:
Passport Number:
Trip Dates:

MonthDayYear
Date
I certify that my travel to Cuba falls under the following authorized category(check one):
Other (please specify, consistent with OFAC rules):
Traveler Statement:
I confirm that my travel to Cuba is consistent with the category selected above and will comply with U.S. law. I understand that knowingly providing false information may subject me to penalties under U.S. law.
Traveler Signature:
Date:

MonthDayYear
Date
Should be Empty:

Black Travelers International – Traveler Certification