Lacey Act Declaration Form

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

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

PreAmendment for Species. The Scientific Name is NOT the trade/common name of the plant.

15. Country of Harvest: Enter the country where the plant was harvested (example: See below). If the country of harvest varies, and is unkno

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 belo

kg - kilograms

m - meter

m2 - square meters

m3 - 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%).

12.ENTERED VALUE: 16.QUANTITY OF 17.UNIT

(in U.S.Dollars) Genus Species PLANT MATERIAL

1354 Quercus lineata 500 kg

8442 Fraxinus excelsior 52 M3

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.

Page 2

" I certify that all chemical substances in this shipment comply with all applicable rules or orders under TSCA and that I am not

offering a chemical substance for entry in violation of TSCA or any applicable rule or order under TSCA."

9401692010

Bentwood Seats Made of Oak

Indonesia

4407950000

European ash lumber (2" x 4")

Switzerland

15.COUNTRY OF

18. PERCENT RECYCLED

(no dashes/symbols)

ARTICLE

HARVEST:

MATERIAL:

11.HTSUS NUMBER:

13.ARTICLE/COMPONENT OF

14.PLANT SCIENTIFIC NAME: