_______________________（date and place）__________________
I，the undersigned，at
test that the above-mentioned evidence is taken lawfully and the signature of the above person is genuine．
_______________（signature of judicial officer who takes the evidence）_____________________________________（date and place）________________________
6（中文版）
有关被扣押物品的证明书
（当美方是请求方时）
我叫_______（姓名），我知道，如果我故意作出不真实的陈述，将有可能依照中华人民共卡口国的法律负刑事责任，谨声明如下：
我正式的政府职位是___________________（官方职务）。我于___________________（日期）在______________________（地点）从_______________________________（人名或机构名）处收到了下列扣押物品。我于______________（日期）在________________（地点）将下列扣押物品原样（如有变化，则说明如下）交给了_________________________（人名或机构名）。
物品说明：
在我保管时物品状况的改变情况：
签名________ 日期___________
部门负责人签名（或加盖本部门公章）：_________________
6（英文版）
When U．S．is Requesting Party CERTIFICATE WITH RESPECT TO SEIZED ITEMS
I，the undersigned，_____________（name）________________________，knowing that I will be subject to criminal liability under the laws of the People’s Republic of China for an intentionally false statement declare that：My official government position is__________________________（official title）___________________________．
I received custody of the items listed below from____________________（name of person or entity）____________on__________________（date）_________________，at_________________（place）________________．I relinquished custody of the items listed below to______________________________________（name of person or entity）_________________________on_________________（date）__________________，at___________________（place）______________________in the same condition as when I received them（or，if different，as noted below）．
