TEMPORARY DEPOSIT RECEIPTTEMPORARY DEPOSIT RECEIPT American Museum of the Cuban DiasporaStep 1 of 425%Date MM slash DD slash YYYY The American Museum of the Cuban Diaspora has received from:Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneFax:Email For The Following Purpose (s):Identification:Examination for: Gift Loan LoanOther:Scheduled Date of Removal: MM slash DD slash YYYY Description of Objects The object(s) described above has been received by the American Museum of the Cuban Diaspora subject to the conditions stated.Received By:Received By:Date MM slash DD slash YYYY The depositor acknowledges that the above listed object (s) have been returned in satisfactory condition.Depositor:Depositor:Date MM slash DD slash YYYY CONDITIONS* I agree to the privacy policy.CONDITIONS The American Museum of the Cuban Diaspora will exercise the same care with respect to the object (s) described in this receipt, as it does in the safekeeping of the comparable property of its own. American Museum of the Cuban Diaspora cannot, however, accept any responsibility whatsoever for objects deposited on an examination status which are left at the owner’s risk. Unless otherwise agreed to in writing, no insurance will be carried by the American Museum of the Cuban Diaspora on objects deposited for examination. The owner hereby releases American Museum of the Cuban Diaspora from liability for any and all claims arising out of any loss of or damage to the object (s) so deposited. Responsibility for insurance is that of the owner. Upon reasonable notice from the depositor or from his duly authorized and accredited or legal representative, any objects listed on this receipt which have not already been accepted by the American Museum of the Cuban Diaspora pursuant to an offer of gift or sale made by the depositor, or which are not included as a loan in a special exhibition then on display, may be withdrawn during the regular Museum hours by surrendering this receipt or upon presentation of the depositor’s written order. Should the American Museum of the Cuban Diaspora accept the objects described in this form as a loan, gift or purchase, this examination receipt will be superseded, with respect to the specific objects involved, by documents appropriate to the transaction. The American Museum of the Cuban Diaspora will give reasonable notice to the depositor, at the address appearing on the receipt, to take back or remove the deposited property. If such objects or property, are not withdrawn by the depositor or the duly authorized and accredited agent or legal representative at the expiration of a period of thirty (30) days after such notice, they may be placed in storage in any warehouse company at the depositor’s risk and expense. After 3 years the objects will become the property of the American Museum of the Cuban Diaspora. The American Museum of the Cuban Diaspora reserves the right to photograph the object(s) described in this receipt. This receipt must be surrendered when the object(s) is returned. I have read and agree to the above CONDITIONS, and I certify that I have full authority to agree thereto:
