Lacey Act Declaration Form

ManualsBrandsModus Furniture ManualsDressersParagon 4-Drawer Truffle Dresser 42 in. H x 60 in. W x 19 in. D

According to the Paperwork reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control

OMB APPROVED

number. The valid OMB control number for this information collection is 0579-0349. The time required to complete this information collection is estimated to average 0.5 hours per response,

0579-0349

including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Exp. Date:

SECTION 1 - Shipment Information

1.ESTIMATED DATE OF ARRIVAL:(MM/DD/YYYY) 6.IMPORTER NAME:

June 01, 2019 Modus Furniture International

2.ENTRY NUMBER: 7.IMPORTER ADDRESS:

5410 Mc Connell Avenue

Los Angeles, CA 90066 U.S.A

3.CONTAINER NUMBER:

EGSU9025958

8.CONSIGNEE NAME:

4.BILL OF LADING:

Living Spaces Furniture

: EGLV081900086030

10.DESCRIPTION OF MERCHANDISE:

9.CONSIGNEE ADDRESS:

5.MID:

18,626.00

Rialto DC 3994 S Riverside Ave

Colton, CA 92324-US

SECTION 2-Compliance with Lacey Act Requirements(16 U.S.C.3372(f))

For each article or component of an article, provide the following:

12.ENTERED VALUE: 16.QUANTITY OF 17.UNIT

(in U.S.Dollars) Genus Species PLANT MATERIAL

9403.50.9045

ROLL SLAT 12 PC QN POPULUS DELTOIDES CHINA 0.292

m3 0%

9403.50.9045

ROLL SLAT 14 PC CK POPULUS DELTOIDES CHINA 0.068

m3 0%

9403.50.9045

ROLL SLAT 12 PC EK POPULUS DELTOIDES CHINA 0.031

m3 0%

9403.50.9080

PARAGON NS TRUFFLE ALBAZIA CHINENSIS INDONESIA 0.066

m3 0%

9403.50.9080

PARAGON NS TRUFFLE EUCALYPTUS DELTOIDES INDONESIA 0.066

m3 0%

9403.50.9080

PARAGON NS TRUFFLE MAHOGANY SWIETENIA INDONESIA 0.442

m3 0%

9403.50.9080

PARAGON NS TRUFFLE SPECIAL MDF MALAYSIA 0.034

m3 0%

9403.50.9080

PARAGON DRESSER TRUFFLE ALBAZIA CHINENSIS INDONESIA 0.266

m3 0%

9403.50.9080

PARAGON DRESSER TRUFFLE EUCALYPTUS DELTOIDES INDONESIA 0.266

m3 0%

9403.50.9080

PARAGON DRESSER TRUFFLE MAHOGANY SWIETENIA INDONESIA 0.478

m3 0%

9403.50.9080

PARAGON DRESSER TRUFFLE SPECIAL MDF MALAYSIA 0.135

m3 0%

9403.50.9080

PARAGON DRESSER MIRROR TRUFFLE

MAHOGANY SWIETENIA INDONESIA 0.017

m3 0%

9403.50.9080

PARAGON DRESSER MIRROR TRUFFLE

SPECIAL MDF MALAYSIA 0.009

m3 0%

9403.50.9080

PARAGON CHEST TRUFFLE ALBAZIA CHINENSIS INDONESIA 0.182

m3 0%

9403.50.9080

PARAGON CHEST TRUFFLE EUCALYPTUS DELTOIDES INDONESIA 0.182

m3 0%

9403.50.9080

PARAGON CHEST TRUFFLE MAHOGANY SWIETENIA INDONESIA 0.342

m3 0%

9403.50.9080

PARAGON CHEST TRUFFLE POPULUS DELTOIDES CHINA 0.012

m3 0%

9403.50.9080

PARAGON CHEST TRUFFLE SPECIAL MDF MALAYSIA 0.105

m3 0%

9403.50.9045

PARAGON QN HB+FB TRUFFLE MAHOGANY SWIETENIA INDONESIA 0.368

m3 0%

9403.50.9045

PARAGON QN SR+SL TRUFFLE MAHOGANY SWIETENIA INDONESIA 0.007

m3 0%

9403.50.9045

PARAGON QN SR+SL TRUFFLE POPULUS DELTOIDES CHINA 0.064

m3 0%

11.HTSUS NUMBER:

13.ARTICLE/COMPONENT OF

14.PLANT SCIENTIFIC NAME:

Plant and Plant Product

Declaration Form

Section 3: Lacey Act Amendment (16 U.S.C. 3372)

U.S.DEPARTMENT OF AGRICULTURE

15.COUNTRY OF

18. PERCENT RECYCLED

(no dashes/symbols)

ARTICLE

HARVEST:

MATERIAL:

Summary of content (4 pages)

PAGE 1
According to the Paperwork reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control OMB APPROVED number. The valid OMB control number for this information collection is 0579-0349. The time required to complete this information collection is estimated to average 0.
PAGE 2
9403.50.9045 PARAGON QN SR+SL TRUFFLE SPECIAL MDF MALAYSIA 0.003 m3 0% 9403.50.9045 PARAGON STRG 4 DRW TRUFFLE ALBAZIA CHINENSIS INDONESIA 0.134 m3 0% 9403.50.9045 PARAGON STRG 4 DRW TRUFFLE EUCALYPTUS DELTOIDES INDONESIA 0.134 m3 0% 9403.50.9045 PARAGON STRG 4 DRW TRUFFLE MAHOGANY SWIETENIA INDONESIA 0.112 m3 0% 0.011 m3 0% 0% 9403.50.9045 PARAGON STRG 4 DRW TRUFFLE SPECIAL MDF MALAYSIA 9403.50.9045 PARAGON STRG 4 DRW TRUFFLE SPECIAL PARTICLEBOARD THAILAND 0.
PAGE 3
9403.50.9045 PARAGON QN SR+SL WHITE POPULUS DELTOIDES CHINA 0.096 m3 0% 9403.50.9045 PARAGON QN SR+SL WHITE SPECIAL MDF MALAYSIA 0.005 m3 0% 9403.50.9045 PARAGON EK HB+FB WHITE MAHOGANY SWIETENIA INDONESIA 0.095 m3 0% 9403.50.9045 PARAGON EK HB+FB WHITE SPECIAL PARTICLEBOARD THAILAND 0.049 m3 0% 0.005 m3 0% 0% 0% 9403.50.9045 PARAGON EK SR+SL WHITE MAHOGANY SWIETENIA INDONESIA 9403.50.9045 PARAGON EK SR+SL WHITE POPULUS DELTOIDES CHINA 0.034 m3 9403.50.
PAGE 4
PreAmendment for Species. The Scientific Name is NOT the trade/common name of the plant. 15. Country of Harvest: Enter the country where the plant was harvested (example: See below). If the country of harvest varies, and is unkno enter all countries from which the plant material in the product may have been harvested. This is NOT the country of manufacture/origin. 16. Quantity of Material: How much plant material is in the shipment (example: See below). 17.