Lacey Act Declaration Form
15. Country of Harvest: Enter the country where the plant was harvested (example: See below). If the country of harvest varies, and is unknown,
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. Unit: This is the Unit of Measure of the Plant Material. Use the drop down box on the form to enter the units for #17. (example: See below).
kg - kilograms
m - meter
m
2
- square meters
m
3
- cubic meters
18. % Recycled Material: If the product is paper or paperboard, enter the percentage of recycled material it contains (0 - 100%). If the percentage
of recycled material varies, enter the average percentage of recycled material used in the product (example: If the percentage of recycled
material used is between 25% and 45%, enter 35%).
Submission of Paper Declaration: Importers should have a copy of the form available for Customs and Border Protection (CBP) to review at the
port of entry. After CBP clears the shipment, the importer must mail the original form to the USDA at the following address:
The Lacey Act
c/o U.S. Department of Agriculture
Box 10
4700 River Road
Riverdale, MD 20737
Note: You may use Form PPQ 505B should more space be required. Make as many copies as necessary.
Failure to include any and all of the required information will result in the rejection of your declaration.
SPECIAL NOTE: IF YOU HAVE FILED A LACEY ACT DECLARATION ELECTRONICALLY THROUGH THE CUSTOMS SYSTEM, THERE IS
NO NEED TO FILE A PAPER DECLARATION.
Version 08-15-2011-0856
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11. HTSUS
Number
12. Entered
Value
13. Article/Component of Article 14. Plant Scientific Name
15.Country of
Harvest
16. Quantity of
Plant Material
17. Unit
18. Percent
Recycled
Genus Species
9401692010 1354 Bentwood Seats Made of Oak Quercus lineata Indonesia 500 kg 0
4407950000 8442 European ash lumber (2" x 4") Fraxinus excelsior Switzerland 52 M3 0