Lacey Act Declaration Form

ManualsBrandsModus Furniture ManualsDressersBrighton 9-Drawer Cinnamon Dresser 41 in. H x 63 in. W x 20 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:

February 12, 2020 Modus Furniture International

2.ENTRY NUMBER: 7.IMPORTER ADDRESS:

5410 Mc Connell Avenue

Los Angeles, CA 90066 U.S.A

3.CONTAINER NUMBER:

TCNU8408057

8.CONSIGNEE NAME:

4.BILL OF LADING:

: Mancini's Sleep World (Agency)

: TFEN34374

10.DESCRIPTION OF MERCHANDISE:

9.CONSIGNEE ADDRESS:

5.MID:

18,686.00 599 Hawthorne Place

Livermore , CA 94550 USA

Phone : 925-456-6400

Fax : 925-456-6440

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

NEVIS PF TW HB+FB ESPRESSO SPECIAL MDF MALAYSIA 0.0454

m3 0%

9403.50.9045

NEVIS PF TW HB+FB ESPRESSO Swietenia Macrophylla Indonesia 0.0569

m3 0%

9403.50.9045

NEVIS PF FL HB+FB ESPRESSO SPECIAL MDF MALAYSIA 0.0419

m3 0%

9403.50.9045

NEVIS PF FL HB+FB ESPRESSO Swietenia Macrophylla Indonesia 0.0409

m3 0%

9403.50.9045

NEVIS PF QN HB+FB ESPRESSO SPECIAL MDF MALAYSIA 0.0935

m3 0%

9403.50.9045

NEVIS PF QN HB+FB ESPRESSO Swietenia Macrophylla Indonesia 0.0842

m3 0%

9403.50.9080

NEVIS 5 DRW CHEST ESPRESSO albizia lebbeck Indonesia 0.2359

m3 0%

9403.50.9080

NEVIS 5 DRW CHEST ESPRESSO SHOREA Laevis Ridl INDONESIA 0.2359

m3 0%

9403.50.9080

NEVIS 5 DRW CHEST ESPRESSO SPECIAL MDF MALAYSIA 0.0335

m3 0%

9403.50.9080

NEVIS 5 DRW CHEST ESPRESSO SPECIAL PARTICLEBOARD THAILAND 0.0181

m3 0%

9403.50.9080

NEVIS 5 DRW CHEST ESPRESSO Swietenia Macrophylla Indonesia 0.0225

m3 0%

9403.50.9080

NEVIS NS 1 DRW ESPRESSO albizia lebbeck Indonesia 0.0223

m3 0%

9403.50.9080

NEVIS NS 1 DRW ESPRESSO SHOREA Laevis Ridl INDONESIA 0.0223

m3 0%

9403.50.9080

NEVIS NS 1 DRW ESPRESSO SPECIAL MDF MALAYSIA 0.0137

m3 0%

9403.50.9080

NEVIS NS 1 DRW ESPRESSO SPECIAL PARTICLEBOARD THAILAND 0.0518

m3 0%

9403.50.9080

NEVIS NS 1 DRW ESPRESSO Swietenia Macrophylla Indonesia 0.0312

m3 0%

9403.50.9045

RIVA PF QN HB+FB ESPRESSO SPECIAL MDF MALAYSIA 0.0312

m3 0%

9403.50.9045

RIVA PF QN HB+FB ESPRESSO SPECIAL PARTICLEBOARD THAILAND 0.0080

m3 0%

9403.50.9045

RIVA PF QN HB+FB ESPRESSO Swietenia Macrophylla INDONESIA 0.0694

m3 0%

9403.50.9045

RIVA PF FL HB+FB ESPRESSO SPECIAL MDF MALAYSIA 0.0470

m3 0%

9403.50.9045

RIVA PF FL HB+FB ESPRESSO SPECIAL PARTICLEBOARD THAILAND 0.0121

m3 0%

11.HTSUS NUMBER:

13.ARTICLE/COMPONENT OF

14.PLANT SCIENTIFIC NAME:

15.COUNTRY OF

18. PERCENT RECYCLED

(no dashes/symbols)

ARTICLE

HARVEST:

MATERIAL:

Plant and Plant Product

Declaration Form

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

U.S.DEPARTMENT OF AGRICULTURE

Summary of content (6 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 RIVA PF FL HB+FB ESPRESSO Swietenia Macrophylla INDONESIA 0.1097 m3 0% 9403.50.9045 ROLL SLAT 12 PC TW POPULUS DELTOIDES CHINA 0.0644 m3 0% 9403.50.9045 ROLL SLAT 12 PC FL POPULUS DELTOIDES CHINA 0.4376 m3 0% 9403.50.9045 ROLL SLAT 12 PC QN POPULUS DELTOIDES CHINA 0.6077 m3 0% 0.1704 m3 0% 0% 9403.50.9045 ROLL SLAT 14 PC CK POPULUS DELTOIDES CHINA 9403.50.9045 ROLL SLAT 12 PC EK POPULUS DELTOIDES CHINA 0.1232 m3 9403.50.
PAGE 3
9403.50.9045 RIVA PF TW/FL SR-01 ESPRESSO POPULUS DELTOIDES CHINA 0.1827 m3 0% 9403.50.9045 RIVA PF TW/FL SR-01 ESPRESSO Swietenia Macrophylla Indonesia 0.0418 m3 0% 9403.50.9045 ZRE FL SR01 ESPRESSO POPULUS DELTOIDES CHINA 0.0266 m3 0% 9403.50.9045 ZRE FL SR01 ESPRESSO Swietenia Macrophylla Indonesia 0.0076 m3 0% 0.1420 m3 0% 0% 9403.50.9045 ZRE QN SR01 ESPRESSO POPULUS DELTOIDES CHINA 9403.50.9045 ZRE QN SR01 ESPRESSO Swietenia Macrophylla Indonesia 0.
PAGE 4
9403.50.9045 SIMPLE STRG EK HB+FB ESPRESSO Swietenia Macrophylla Indonesia 0.0063 m3 0% 9403.50.9045 RIVA STRG FL HB+FB ESPRESSO SPECIAL MDF MALAYSIA 0.0315 m3 0% 9403.50.9045 RIVA STRG FL HB+FB ESPRESSO SPECIAL PARTICLEBOARD THAILAND 0.0084 m3 0% 9403.50.9045 RIVA STRG FL HB+FB ESPRESSO Swietenia Macrophylla INDONESIA 0.0651 m3 0% 0.0277 m3 0% 0% 9403.50.9045 RIVA STRG CK HB+FB ESPRESSO SPECIAL MDF MALAYSIA 9403.50.
PAGE 5
9403.50.9045 ELEMENT_RTA PF FL HB+FB CHOCOLATE_BROWN Swietenia Macrophylla Indonesia 0.4846 m3 0% 9403.50.9045 ELEMENT_RTA PF QN HB+FB CHOCOLATE_BROWN SPECIAL MDF MALAYSIA 0.0733 m3 0% 9403.50.9045 ELEMENT_RTA PF QN HB+FB CHOCOLATE_BROWN SPECIAL PARTICLEBOARD THAILAND 0.1364 m3 0% 9403.50.9045 ELEMENT_RTA PF QN HB+FB CHOCOLATE_BROWN Swietenia Macrophylla Indonesia 0.3530 m3 0% 0.0578 m3 0% 0% 9403.50.9045 ELEMENT_RTA PF CK HB+FB CHOCOLATE_BROWN SPECIAL MDF MALAYSIA 9403.
PAGE 6
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.