(Address in the US) (Address in Mexico) Bajo protesta de decir verdad, manifiesto a usted que es mi intención residir en México de manera (Temporal/Permanente) y que los artículos que detallo a continuación pertenecen a mi menaje de casa, los cuales fueron utilizados durante la estancia en los Estados Unidos. Under oath of truthfulness, I declare that I have the intention to live in Mexico on a (Temporary/Permanent) basis and that the below mentioned items belong to my household goods inventory which I used during my residency in the US. Cantidad (Number) 1 1 1 1 2 1 3 2 4 Descripción (Description) Televisión/ TV Estéreo/ Sound System Horno de microondas/ Microwave Refrigerador/ Refrigerator Cajas con ropa/ Boxes with clothing Caja con utensilios de cocina/ Box with kitchenware Cajas con libros/ Boxes with books Mesas/ Tables Sillas de madera/ Wooden chairs Marca (Brand) Sony Modelo (Model) TRINITRON Número de serie (Serial number) HDF75-896-0125D Panasonic SCH039 DLKFGF-58-96 LG S200 SB509-24-99123 Samsung WRB322DMBW RDBM870924 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A _____________________________ Name and signature of the petitioner Instructions: 1. All electronic devices and appliances have to be fully described by brand, model, and serial number. 2. Smaller articles should be packed and listed in boxes. 3. Furniture must be carefully described. 4. The household goods import does not include weapons, explosive, alcohol beverages, medicines, food, spices, motorcycles, trucks and cars. 5. You will be required to sign this inventory in front of the consular officer in charge of processing your petition.