Lacey Act Declaration Form

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%
9403.50.9045
ELEMENT_RTA PF CK HB+FB CHOCOLATE_BROWN SPECIAL MDF MALAYSIA 0.0578
m3 0%
9403.50.9045
ELEMENT_RTA PF CK HB+FB CHOCOLATE_BROWN SPECIAL PARTICLEBOARD THAILAND 0.1048
m3 0%
9403.50.9045
ELEMENT_RTA PF CK HB+FB CHOCOLATE_BROWN Swietenia Macrophylla Indonesia 0.2501
m3 0%
9403.50.9080
CITY_II NS PWRO BASALT_GREY albizia lebbeck Indonesia 0.0132
m3 0%
9403.50.9080
CITY_II NS PWRO BASALT_GREY SHOREA Laevis Ridl INDONESIA 0.0132
m3 0%
9403.50.9080
CITY_II NS PWRO BASALT_GREY SPECIAL MDF MALAYSIA 0.0141
m3 0%
9403.50.9080
CITY_II NS PWRO BASALT_GREY SPECIAL PARTICLEBOARD THAILAND 0.0186
m3 0%
9403.50.9080
CITY_II NS PWRO BASALT_GREY Swietenia Macrophylla Indonesia 0.0260
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
1/12/2020
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
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