Lacey Act Declaration Form

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%
9403.50.9045
PARAGON EK SR+SL WHITE MAHOGANY SWIETENIA INDONESIA 0.005
m3 0%
9403.50.9045
PARAGON EK SR+SL WHITE POPULUS DELTOIDES CHINA 0.034
m3 0%
9403.50.9045
PARAGON EK SR+SL WHITE SPECIAL MDF MALAYSIA 0.002
m3 0%
I certify under penalty of perjury that, to the best of my knowledge and belief, the information furnished is true and correct:
Version 08-15-2011-0856
PPQ FORM 505
DYAH ENDRASTI
AUGUST 2011
Preparer's Phone Number and Area Code Signature Type or Print Name
5/2/2019
Page 1
Knowingly making a false statement in this declaration for Importation may subject the declarant to criminal penalties in accordance with 16 U.S.C.3373(d).
Version 08-15-2011-0856
1. Estimated Date of Arrival: Enter the date (MM/DD/YYYY) that the product is expected to enter the United States of America.
2. Entry Number: Enter the U. S. Customs entry number assigned to this shipment. (Format: xxx-xxxxxxx-x)
3. Container Number: Enter the number of the shipping container in which the product is being shipped - available from your shipping company.
If you have more than container number in your shipment, check the "see attachment" box, and list all of the containers on a separate sheet.
Attach the container list to the PPQ 505. If there is no container number, please leave this section blank.
4. Bill of Lading: Enter the Bill of Lading (BOL) number assigned to this shipment - available from the shipping company. If there is no Bill of
Lading number, please leave this section blank.
5. MID: Manufacturer Identification Code - available from the manufacturer or customs broker (19 CFR Appendix to Part 102).
6. Importer Name: Enter the name of the import company or individual for the product.
7. Importer Address: Enter the address of the import company or individual in #6.
8. Consignee Name: Name of the individual or company who ordered and will ultimately receive the shipment.
9. Consignee Address: Enter the address of the individual or company in #8.
10. Description of the Merchandise: Enter the name of the plant or plant product, and its use (example: wooden spoons for kitchenware). If the use
is unknown, enter only the name of the product (example: lumber). If the product is protected under CITES also input CITES permit number
here. If product was manufactured prior to the Lacey Act Amendment also input "Manufactured Prior to May 22, 2008".
11. HTSUS Number: Enter the Harmonized Tariff Code for the merchandise described in #10 - available at http://www.usitc.gov/tata/hts/.
12. Entered Value (in U.S. Dollars): Write the entered value of the imported merchandise described in #10 in U.S. Dollars.
13. Article/Component of Article: Enter a brief description of each article, or component of an article, that is manufactured from plants or plant
parts. (Example: A decorative item including a wood frame and 100 % recycled paperboard - enter the frame as a line item, and record the
percent recycled material in the paperboard in section #18.)
14. Plant Scientific Name: For each article/component in #13 enter the scientific name (example: See next page). If the species of plant used to
produce the product varies, and the species used to produce the product is unknown, enter each species that may have been used to produce the
product. If product was manufactured prior to the Amendment and you cannot determine species, enter "Special" for Genus and
Tel [phone]
DYAH ENDRASTI