_________________________whose photograph is attached hereto on the date and at the place hereunder mentioned the sum of Five Hundred Dollars being the head tax due under the provisions of the Chinese Immigration Act. 
The above mentioned party who claims to be a native of ______  in the _______ of  ________ of the age of ____ years arrived or landed at _______ on the  _____ day of _____  19__ ex _________ 
The declaration in this case is ____ No. _____
Dated at ______ on _____ 19__ 

Sig: ________________________.
Controller of Chinese Immigration