There is no required format for this report; however, the attached model report is provided as a courtesy.
The elements of the report prescribed in 19 CFR 111.30(d) may be compiled on a sheet of paper and submitted to CBP along with the money order or check for the corresponding fee. Again, the attached model report is only a suggested format and its use is not mandatory.
Please be reminded, licensed Customs brokers must present an employee list, if applicable, along with each status report submitted to CBP in accordance with 19 CFR 111.28(b). In addition, each individually licensed broker must state whether or not he/she still meets the applicable requirements of 19 CFR 111.11 and 111.19 and has not engaged in any conduct that could constitute grounds for suspension or revocation under section 111.53.