Form 486A Import Declaration for Ephedrine, Pseudoephedrine and Ph

Please complete Copy 1 (Page 1 and 2) Only. Information will be transferred to Copy 2 and Copy 3.
U.S. Department of Justice

Import Declaration for Ephedrine, Pseudoephedrine
and Phenylpropanolamine
OMB Approval No. 1117-0023

SEE INSTRUCTIONS FOR PRIVACY ACT
1. Type of Submission:
NOTICE!

[ ] ORIGINAL

[ ] AMENDED

Drug Enforcement Administration

[ ] WITHDRAWAL

Expiration Date: 9/30/2016

DEA TRANSACTION ID NUMBER:

A 15-day advance notice is required for all U.S. imports of Ephedrine, Pseudoephedrine, and Phenylpropanolamine.

2a. NAME OF IMPORTER

2b. ADDRESS OF IMPORTER

2c. DEA REGISTRATION NUMBER:
2d. TELEPHONE NO. OF IMPORTER

2e. E-MAIL ADDRESS OF IMPORTER

2f. PURCHASE/INVOICE NO. (optional)

3a. NAME OF FOREIGN EXPORTER

3b. ADDRESS OF FOREIGN EXPORTER

4a. NAME OF FOREIGN MANUFACTURER (If same as 3a, enter
“Same as 3a”)

4b. ADDRESS OF FOREIGN MANUFACTURER

5a. NAME OF FOREIGN DISTRIBUTOR (If applicable)

5b. ADDRESS OF FOREIGN DISTRIBUTOR (If applicable)

EPHEDRINE, PSEUDOEPHEDRINE, AND PHENYLPROPANOLAMINE TO BE IMPORTED
6a. Name and Description of chemical
appearing on label or container and
DEA Chemical Code (see 21 CFR
§1310.02).

6b. Import Quota

6c. Number of containers, size, net weight
(express as base) in kilograms for each
chemical listed. For drug products, show
number of dosage units.

6d. Actual Date of Import; Name of
each chemical imported and its
Actual Net Weight (To be
completed by importer).

Current year Quota

[

]

Quota used to date
for current year

Amount of Quota
remaining

7a. FOREIGN PORT OF EXPORTATION:

APPROX. DEPARTURE DATE:

7b. DOMESTIC PORT OF IMPORTATION:

APPROX. ARRIVAL DATE:

8. MODE OF TRANSPORTATION and NAME OF VESSEL or NAME OF CARRIER:
9. RETURN DECLARATION FOR IMPORTER. MUST be returned within 30 days from actual date of import (6d).
SIGNATURE:
DEA FORM – 486A (Previous version obsolete.)

DATE:
Page 1

Copy 1

LIST TRANSFEREE(S) ON INITIAL SUBMISSION OF DECLARATION. USE ANOTHER
SHEET IF MORE THAN 3 TRANFEREES.

DEA TRANSACTION ID NUMBER:

10a. NAME OF TRANSFEREE OF IMPORT

10b. ADDRESS OF TRANSFEREE OF IMPORT

10c. DEA REGISTRATION NUMBER (If applicable):

10d. TELEPHONE NUMBER:

10e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

10f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee

10g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:
11a. NAME OF TRANSFEREE OF IMPORT

DATE:
11b. ADDRESS OF TRANSFEREE OF IMPORT

11c. DEA REGISTRATION NUMBER (If applicable):

11d. TELEPHONE NUMBER:

11e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

11f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee.

11g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:
12a. NAME OF TRANSFEREE OF IMPORT

DATE:
12b. ADDRESS OF TRANSFEREE OF IMPORT

12c. DEA REGISTRATION NUMBER (If applicable):

12d. TELEPHONE NUMBER:

12e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

12f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee.

12g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:

DATE:

13. SIGNATURE OF IMPORTER (Print or Type Name below Signature)
DATE:
DEA FORM – 486A (Previous version obsolete.)

Reset Form

Page 2

Print Form

Copy 1

Save a Copy

U.S. Department of Justice

Import Declaration for Ephedrine, Pseudoephedrine
and Phenylpropanolamine
OMB Approval No. 1117-0023

SEE INSTRUCTIONS FOR PRIVACY ACT
1. Type of Submission:
NOTICE!

[ ] ORIGINAL

[ ] AMENDED

Drug Enforcement Administration

[ ] WITHDRAWAL

Expiration Date: 9/30/2016

DEA TRANSACTION ID NUMBER:

A 15-day advance notice is required for all U.S. imports of Ephedrine, Pseudoephedrine, and Phenylpropanolamine.

2a. NAME OF IMPORTER

2b. ADDRESS OF IMPORTER

2c. DEA REGISTRATION NUMBER:
2d. TELEPHONE NO. OF IMPORTER

2e. E-MAIL ADDRESS OF IMPORTER

2f. PURCHASE/INVOICE NO. (optional)

3a. NAME OF FOREIGN EXPORTER

3b. ADDRESS OF FOREIGN EXPORTER

4a. NAME OF FOREIGN MANUFACTURER (If same as 3a, enter
“Same as 3a”)

4b. ADDRESS OF FOREIGN MANUFACTURER

5a. NAME OF FOREIGN DISTRIBUTOR (If applicable)

5b. ADDRESS OF FOREIGN DISTRIBUTOR (If applicable)

EPHEDRINE, PSEUDOEPHEDRINE, AND PHENYLPROPANOLAMINE TO BE IMPORTED
6a. Name and Description of chemical
appearing on label or container and
DEA Chemical Code (see 21 CFR
§1310.02).

6b. Import Quota

6c. Number of containers, size, net weight
(express as base) in kilograms for each
chemical listed. For drug products, show
number of dosage units.

6d. Actual Date of Import; Name of
each chemical imported and its
Actual Net Weight (To be
completed by importer).

Current year Quota

[

]

Quota used to date
for current year

Amount of Quota
remaining

7a. FOREIGN PORT OF EXPORTATION:

APPROX. DEPARTURE DATE:

7b. DOMESTIC PORT OF IMPORTATION:

APPROX. ARRIVAL DATE:

8. MODE OF TRANSPORTATION and NAME OF VESSEL or NAME OF CARRIER:
9. RETURN DECLARATION FOR IMPORTER. MUST be returned within 30 days from actual date of import (6d).
SIGNATURE:
DEA FORM – 486A (Previous version obsolete.)

DATE:
Page 1

Copy 2

LIST TRANSFEREE(S) ON INITIAL SUBMISSION OF DECLARATION. USE ANOTHER
SHEET IF MORE THAN 3 TRANFEREES.

DEA TRANSACTION ID NUMBER:

10a. NAME OF TRANSFEREE OF IMPORT

10b. ADDRESS OF TRANSFEREE OF IMPORT

10c. DEA REGISTRATION NUMBER (If applicable):

10d. TELEPHONE NUMBER:

10e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

10f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee

10g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:
11a. NAME OF TRANSFEREE OF IMPORT

DATE:
11b. ADDRESS OF TRANSFEREE OF IMPORT

11c. DEA REGISTRATION NUMBER (If applicable):

11d. TELEPHONE NUMBER:

11e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

11f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee.

11g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:
12a. NAME OF TRANSFEREE OF IMPORT

DATE:
12b. ADDRESS OF TRANSFEREE OF IMPORT

12c. DEA REGISTRATION NUMBER (If applicable):

12d. TELEPHONE NUMBER:

12e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

12f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee.

12g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:

DATE:

13. SIGNATURE OF IMPORTER (Print or Type Name below Signature)
DATE:
DEA FORM – 486A (Previous version obsolete.)

Page 2

Copy 2

U.S. Department of Justice

Import Declaration for Ephedrine, Pseudoephedrine
and Phenylpropanolamine
OMB Approval No. 1117-0023

SEE INSTRUCTIONS FOR PRIVACY ACT
1. Type of Submission:
NOTICE!

[ ] ORIGINAL

[ ] AMENDED

Drug Enforcement Administration

[ ] WITHDRAWAL

Expiration Date: 9/30/2016

DEA TRANSACTION ID NUMBER:

A 15-day advance notice is required for all U.S. imports of Ephedrine, Pseudoephedrine, and Phenylpropanolamine.

2a. NAME OF IMPORTER

2b. ADDRESS OF IMPORTER

2c. DEA REGISTRATION NUMBER:
2d. TELEPHONE NO. OF IMPORTER

2e. E-MAIL ADDRESS OF IMPORTER

2f. PURCHASE/INVOICE NO. (optional)

3a. NAME OF FOREIGN EXPORTER

3b. ADDRESS OF FOREIGN EXPORTER

4a. NAME OF FOREIGN MANUFACTURER (If same as 3a, enter
“Same as 3a”)

4b. ADDRESS OF FOREIGN MANUFACTURER

5a. NAME OF FOREIGN DISTRIBUTOR (If applicable)

5b. ADDRESS OF FOREIGN DISTRIBUTOR (If applicable)

EPHEDRINE, PSEUDOEPHEDRINE, AND PHENYLPROPANOLAMINE TO BE IMPORTED
6a. Name and Description of chemical
appearing on label or container and
DEA Chemical Code (see 21 CFR
§1310.02).

6b. Import Quota

6c. Number of containers, size, net weight
(express as base) in kilograms for each
chemical listed. For drug products, show
number of dosage units.

6d. Actual Date of Import; Name of
each chemical imported and its
Actual Net Weight (To be
completed by importer).

Current year Quota

[

]

Quota used to date
for current year

Amount of Quota
remaining

7a. FOREIGN PORT OF EXPORTATION:

APPROX. DEPARTURE DATE:

7b. DOMESTIC PORT OF IMPORTATION:

APPROX. ARRIVAL DATE:

8. MODE OF TRANSPORTATION and NAME OF VESSEL or NAME OF CARRIER:
9. RETURN DECLARATION FOR IMPORTER. MUST be returned within 30 days from actual date of import (6d).
SIGNATURE:
DEA FORM – 486A (Previous version obsolete.)

DATE:
Page 1

Copy 3

LIST TRANSFEREE(S) ON INITIAL SUBMISSION OF DECLARATION. USE ANOTHER
SHEET IF MORE THAN 3 TRANFEREES.

DEA TRANSACTION ID NUMBER:

10a. NAME OF TRANSFEREE OF IMPORT

10b. ADDRESS OF TRANSFEREE OF IMPORT

10c. DEA REGISTRATION NUMBER (If applicable):

10d. TELEPHONE NUMBER:

10e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

10f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee

10g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:
11a. NAME OF TRANSFEREE OF IMPORT

DATE:
11b. ADDRESS OF TRANSFEREE OF IMPORT

11c. DEA REGISTRATION NUMBER (If applicable):

11d. TELEPHONE NUMBER:

11e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

11f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee.

11g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:
12a. NAME OF TRANSFEREE OF IMPORT

DATE:
12b. ADDRESS OF TRANSFEREE OF IMPORT

12c. DEA REGISTRATION NUMBER (If applicable):

12d. TELEPHONE NUMBER:

12e. Name & Quantity of Ephedrine, Pseudoephedrine, and
Phenylpropanolamine to be Imported for this Transferee. (Enter names as
shown on labels; numbers and sizes of packages; and strength.)

12f. Name & Quantity of Listed Chemical Actually Imported and Date
Transferred to this Transferee.

12g. RETURN DECLARATION (Actual Name & Quantity of Ephedrine, Pseudoephedrine, and Phenylpropanolamine Distributed to the Transferee. MUST be
returned within 30 days from actual date of import (6d). If amount not completely distributed, send a Return Declaration 30 days from the next distribution. If
the whole order was distributed, may say “all import distributed” and the date.
SIGNATURE:

DATE:

13. SIGNATURE OF IMPORTER (Print or Type Name below Signature)
DATE:
DEA FORM – 486A (Previous version obsolete.)

Page 2

Copy 3