Manualshelf

Lacey Act Declaration Form

ManualsBrandsInterbuild ManualsButchers Block Countertops96 in. x 25.5 in. x 1 in. Light Oak Acacia Wood Kitchen Countertop
123
PPQ FORM 505
AUGUST 2011
1. ESTIMATED DATE OF ARRIVAL: (MM/DD/YYYY)
4. BILL OF LADING:
2. ENTRY NUMBER:
8. CONSIGNEE NAME:
9. CONSIGNEE ADDRESS:
7. IMPORTER ADDRESS:
6. IMPORTER NAME:
5. MID:
3. CONTAINER NUMBER:
SECTION 1 - Shipment Information
See Attachment
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).
I certify under penalty of perjury that, to the best of my knowledge and belief, the information furnished is true and correct:
Signature DateType or Print Name
Page 1
Version 08-15-2011-0856
Preparer's Phone Number and Area Code
SECTION 2 - Compliance with Lacey Act Requirements (16 U.S.C. 3372(f))
10. DESCRIPTION OF MERCHANDISE:
11. HTSUS NUMBER:
(no dashes/symbols)
12. ENTERED
VALUE:
14. PLANT SCIENTIFIC NAME: 16. QUANTITY OF
PLANT MATERIAL:
17. UNIT:13. ARTICLE/ COMPONENT OF ARTICLE
For each article or component of an article, provide the following:
18. PERCENT
RECYCLED:
15. COUNTRY
OF HARVEST:
Plant and Plant Product
Declaration Form
Section 3: Lacey Act Amendment (16 U.S.C. 3372)
U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
OMB APPROVED
0579-0349
Exp. Date:
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
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,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Genus Species

Summary of content (3 pages)