486 Import/Export Declaration for List I and List II Chemica

This form should be completed ONLINE and PRINTED on your printer. Complete the first two pages of this form ONLY. The
remaining pages will be completed automatically. Refer to the instructions for guidance on the use of the 4 copies of this form.

Import / Export Declaration
for List I and List II Chemicals

U.S. Department of Justice

Drug Enforcement Administration

OMB Approval No. 1117-0023

SEE REVERSE INSTRUCTIONS FOR PRIVACY ACT
1a. Type of Transaction: [ ] IMPORT [ ] EXPORT [ ] INTERNATIONAL
1c. WARNING!

1b. Type of Submission: [ ] ORIGINAL [ ] AMENDED [ ] WITHDRAWAL

15-day advance notice required for initial shipment or for company that has lost regular importer
or regular customer status. See 21 C.F.R. Part 1313 for further details.
[ ] I certify I have met the conditions for the waiver of 15-day advance notice requirement.

2a. U.S. IMPORTER/ U.S. EXPORTER / U.S. BROKER
(Name, address, telephone, and fax no.)

DEA Transaction Number

2b. IF IMPORT, LIST FOREIGN CONSIGNOR; IF EXPORT OR
INTERNATIONAL TRANSACTION, LIST FOREIGN TRANSFEREE.
(Name, address, telephone, and fax no.)

DEA Registration Number (for List I only):
Foreign permit no. (if applicable)

Purchase/Invoice no.

3. Listed Chemicals to be Imported / Exported / Brokered
3a. Name and Description of chemical
appearing on label or container. For drug
products, show dosage strength and
dosage size.

4a.

[ ] FOREIGN

3b. Name of chemicals as
designated by Title 21 C.F.R.
1310.02

3c. Number of containers, size,
net weight of each chemical
(kg). For drug products,
show number of dosage
units. Show net total weight
per chemical.

[ ] DOMESTIC

4b.

[ ] FOREIGN

PORT OF EXPORTATION:

PORT OF IMPORTATION:

APPROX. DEPARTURE DATE:

APPROX. ARRIVAL DATE:

3d. DATE OF ACTUAL
IMPORT/EXPORT AND
ACTUAL QUANTITY (To be
completed by person named in
(2a).) If same as 3c, write
”same as 3c.”

[ ] DOMESTIC

5. MODE OF TRANSPORTATION, NAME OF VESSEL, OR NAME OF CARRIER:
SIGNATURE OF AUTHORIZED INDIVIDUAL (Print or Type Name below
Signature)

DATE:

Print Name:
DEA form - 486 (Previous version obsolete.)
930

Copy 11

6. RETURN DECLARATION FOR EXPORTS AND INTERNATIONAL TRANSACTIONS (Name & Quantity of List I and List II Chemicals exported to the
Transferee or resulting from International Transaction. MUST be returned within 30 days from actual date of export (3d).

SIGNATURE:

DATE:

For IMPORTS: List TRANSFEREE(S) UPON INITIAL APPLICATION (Names, address, telephone, and fax no.) Fill in 7 through 9. USE SEPARATE SHEET
IF MORE THAN 3 TRANFEREES. For INTERNATIONAL TRANSACTIONS: Show foreign supplier in 7a and 7b only.
7a. NAME OF TRANSFEREE OF IMPORT

7b. ADDRESS OF TRANSFEREE OF IMPORT

7c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

7d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee

7e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual

import (7d) 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:
8a. NAME OF TRANSFEREE OF IMPORT

DATE:
8b. ADDRESS OF TRANSFEREE OF IMPORT

8c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

8d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

8e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days from actual date
of import (8d) 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:
9a. NAME OF TRANSFEREE OF IMPORT

DATE:
9b. ADDRESS OF TRANSFEREE OF IMPORT

9c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

9d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

9e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual
import (9d) 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:
DEA form - 486 (Previous version obsolete.)
9/30/2016

Reset Form

DATE:

Print Form

Complete only the first two pages of form. The
remaining pages will be automatically completed.

Copy 11

Import / Export Declaration
for List I and List II Chemicals

U.S. Department of Justice

Drug Enforcement Administration

OMB Approval No. 1117-0023

SEE REVERSE INSTRUCTIONS FOR PRIVACY ACT
1a. Type of Transaction: [ ] IMPORT [ ] EXPORT [ ] INTERNATIONAL
1c. WARNING!

1b. Type of Submission: [ ] ORIGINAL [ ] AMENDED [ ] WITHDRAWAL

15-day advance notice required for initial shipment or for company that has lost regular importer
or regular customer status. See 21 C.F.R. Part 1313 for further details.
[ ] I certify I have met the conditions for the waiver of 15-day advance notice requirement.

2a. U.S. IMPORTER/ U.S. EXPORTER / U.S. BROKER
(Name, address, telephone, and fax no.)

DEA Transaction Number

2b. IF IMPORT, LIST FOREIGN CONSIGNOR; IF EXPORT OR
INTERNATIONAL TRANSACTION, LIST FOREIGN TRANSFEREE.
(Name, address, telephone, and fax no.)

DEA Registration Number (for List I only):
Foreign permit no. (if applicable)

Purchase/Invoice no.

3. Listed Chemicals to be Imported / Exported / Brokered
3a. Name and Description of chemical
appearing on label or container. For drug
products, show dosage strength and
dosage size.

4a.

[ ] FOREIGN

3b. Name of chemicals as
designated by Title 21 C.F.R.
1310.02

3c. Number of containers, size,
net weight of each chemical
(kg). For drug products,
show number of dosage
units. Show net total weight
per chemical.

[ ] DOMESTIC

4b.

[ ] FOREIGN

PORT OF EXPORTATION:

PORT OF IMPORTATION:

APPROX. DEPARTURE DATE:

APPROX. ARRIVAL DATE:

3d. DATE OF ACTUAL
IMPORT/EXPORT AND
ACTUAL QUANTITY (To be
completed by person named in
(2a).) If same as 3c, write
”same as 3c.”

[ ] DOMESTIC

5. MODE OF TRANSPORTATION, NAME OF VESSEL, OR NAME OF CARRIER:
SIGNATURE OF AUTHORIZED INDIVIDUAL (Print or Type Name below
Signature)

Print Name:

DATE:

Print Name:

DEA form - 486 (Previous version obsolete.)
9/30/2016

Copy 12

6. RETURN DECLARATION FOR EXPORTS AND INTERNATIONAL TRANSACTIONS (Name & Quantity of List I and List II Chemicals exported to the
Transferee or resulting from International Transaction. MUST be returned within 30 days from actual date of export (3d).

SIGNATURE:

DATE:

For IMPORTS: List TRANSFEREE(S) UPON INITIAL APPLICATION (Names, address, telephone, and fax no.) Fill in 7 through 9. USE SEPARATE SHEET
IF MORE THAN 3 TRANFEREES. For INTERNATIONAL TRANSACTIONS: Show foreign supplier in 7a and 7b only.
7a. NAME OF TRANSFEREE OF IMPORT

7b. ADDRESS OF TRANSFEREE OF IMPORT

7c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

7d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee

7e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual

import (7d) 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:
8a. NAME OF TRANSFEREE OF IMPORT

DATE:
8b. ADDRESS OF TRANSFEREE OF IMPORT

8c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

8d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

8e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days from actual date
of import (8d) 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:
9a. NAME OF TRANSFEREE OF IMPORT

DATE:
9b. ADDRESS OF TRANSFEREE OF IMPORT

9c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

9d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

9e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual
import (9d) 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:
DEA form - 486 (Previous version obsolete.)
9/30/2016

DATE:

Copy 21

Import / Export Declaration
for List I and List II Chemicals

U.S. Department of Justice

Drug Enforcement Administration

OMB Approval No. 1117-0023

SEE REVERSE INSTRUCTIONS FOR PRIVACY ACT
1a. Type of Transaction: [ ] IMPORT [ ] EXPORT [ ] INTERNATIONAL
1c. WARNING!

1b. Type of Submission: [ ] ORIGINAL [ ] AMENDED [ ] WITHDRAWAL

15-day advance notice required for initial shipment or for company that has lost regular importer
or regular customer status. See 21 C.F.R. Part 1313 for further details.
[ ] I certify I have met the conditions for the waiver of 15-day advance notice requirement.

2a. U.S. IMPORTER/ U.S. EXPORTER / U.S. BROKER
(Name, address, telephone, and fax no.)

DEA Transaction Number

2b. IF IMPORT, LIST FOREIGN CONSIGNOR; IF EXPORT OR
INTERNATIONAL TRANSACTION, LIST FOREIGN TRANSFEREE.
(Name, address, telephone, and fax no.)

DEA Registration Number (for List I only):
Foreign permit no. (if applicable)

Purchase/Invoice no.

3. Listed Chemicals to be Imported / Exported / Brokered
3a. Name and Description of chemical
appearing on label or container. For drug
products, show dosage strength and
dosage size.

4a.

[ ] FOREIGN

3b. Name of chemicals as
designated by Title 21 C.F.R.
1310.02

3c. Number of containers, size,
net weight of each chemical
(kg). For drug products,
show number of dosage
units. Show net total weight
per chemical.

[ ] DOMESTIC

4b.

[ ] FOREIGN

PORT OF EXPORTATION:

PORT OF IMPORTATION:

APPROX. DEPARTURE DATE:

APPROX. ARRIVAL DATE:

3d. DATE OF ACTUAL
IMPORT/EXPORT AND
ACTUAL QUANTITY (To be
completed by person named in
(2a).) If same as 3c, write
”same as 3c.”

[ ] DOMESTIC

5. MODE OF TRANSPORTATION, NAME OF VESSEL, OR NAME OF CARRIER:
SIGNATURE OF AUTHORIZED INDIVIDUAL (Print or Type Name below
Signature)

Print Name:

DATE:

Print Name:

DEA form - 486 (Previous version obsolete.)
9/30/2016

Copy 13

6. RETURN DECLARATION FOR EXPORTS AND INTERNATIONAL TRANSACTIONS (Name & Quantity of List I and List II Chemicals exported to the
Transferee or resulting from International Transaction. MUST be returned within 30 days from actual date of export (3d).

SIGNATURE:

DATE:

For IMPORTS: List TRANSFEREE(S) UPON INITIAL APPLICATION (Names, address, telephone, and fax no.) Fill in 7 through 9. USE SEPARATE SHEET
IF MORE THAN 3 TRANFEREES. For INTERNATIONAL TRANSACTIONS: Show foreign supplier in 7a and 7b only.
7a. NAME OF TRANSFEREE OF IMPORT

7b. ADDRESS OF TRANSFEREE OF IMPORT

7c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

7d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee

7e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual

import (7d) 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:
8a. NAME OF TRANSFEREE OF IMPORT

DATE:
8b. ADDRESS OF TRANSFEREE OF IMPORT

8c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

8d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

8e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days from actual date
of import (8d) 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:
9a. NAME OF TRANSFEREE OF IMPORT

DATE:
9b. ADDRESS OF TRANSFEREE OF IMPORT

9c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

9d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

9e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual
import (9d) 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:
DEA form - 486 (Previous version obsolete.)
9/30/2016

DATE:

Copy 31

Import / Export Declaration
for List I and List II Chemicals

U.S. Department of Justice

Drug Enforcement Administration

OMB Approval No. 1117-0023

SEE REVERSE INSTRUCTIONS FOR PRIVACY ACT
1a. Type of Transaction: [ ] IMPORT [ ] EXPORT [ ] INTERNATIONAL
1c. WARNING!

1b. Type of Submission: [ ] ORIGINAL [ ] AMENDED [ ] WITHDRAWAL

15-day advance notice required for initial shipment or for company that has lost regular importer
or regular customer status. See 21 C.F.R. Part 1313 for further details.
[ ] I certify I have met the conditions for the waiver of 15-day advance notice requirement.

2a. U.S. IMPORTER/ U.S. EXPORTER / U.S. BROKER
(Name, address, telephone, and fax no.)

DEA Transaction Number

2b. IF IMPORT, LIST FOREIGN CONSIGNOR; IF EXPORT OR
INTERNATIONAL TRANSACTION, LIST FOREIGN TRANSFEREE.
(Name, address, telephone, and fax no.)

DEA Registration Number (for List I only):
Foreign permit no. (if applicable)

Purchase/Invoice no.

3. Listed Chemicals to be Imported / Exported / Brokered
3a. Name and Description of chemical
appearing on label or container. For drug
products, show dosage strength and
dosage size.

4a.

[ ] FOREIGN

3b. Name of chemicals as
designated by Title 21 C.F.R.
1310.02

3c. Number of containers, size,
net weight of each chemical
(kg). For drug products,
show number of dosage
units. Show net total weight
per chemical.

[ ] DOMESTIC

4b.

[ ] FOREIGN

PORT OF EXPORTATION:

PORT OF IMPORTATION:

APPROX. DEPARTURE DATE:

APPROX. ARRIVAL DATE:

3d. DATE OF ACTUAL
IMPORT/EXPORT AND
ACTUAL QUANTITY (To be
completed by person named in
(2a).) If same as 3c, write
”same as 3c.”

[ ] DOMESTIC

5. MODE OF TRANSPORTATION, NAME OF VESSEL, OR NAME OF CARRIER:
SIGNATURE OF AUTHORIZED INDIVIDUAL (Print or Type Name below
Signature)

Print Name:

DATE:

Print Name:

DEA form - 486 (Previous version obsolete.)
9/30/2016

Copy 14

6. RETURN DECLARATION FOR EXPORTS AND INTERNATIONAL TRANSACTIONS (Name & Quantity of List I and List II Chemicals exported to the
Transferee or resulting from International Transaction. MUST be returned within 30 days from actual date of export (3d).

SIGNATURE:

DATE:

For IMPORTS: List TRANSFEREE(S) UPON INITIAL APPLICATION (Names, address, telephone, and fax no.) Fill in 7 through 9. USE SEPARATE SHEET
IF MORE THAN 3 TRANFEREES. For INTERNATIONAL TRANSACTIONS: Show foreign supplier in 7a and 7b only.
7a. NAME OF TRANSFEREE OF IMPORT

7b. ADDRESS OF TRANSFEREE OF IMPORT

7c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

7d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee

7e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual

import (7d) 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:
8a. NAME OF TRANSFEREE OF IMPORT

DATE:
8b. ADDRESS OF TRANSFEREE OF IMPORT

8c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

8d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

8e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days from actual date
of import (8d) 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:
9a. NAME OF TRANSFEREE OF IMPORT

DATE:
9b. ADDRESS OF TRANSFEREE OF IMPORT

9c. Name & Quantity of List I and List II chemical to be Imported for this
transferee. (Enter names as shown on labels; numbers and sizes of packages;
and strength.)

9d. Name & Quantity of List I and List II Chemical Actually Imported and
Date Imported for this Transferee.

9e. RETURN DECLARATION (Name & Quantity of List I and List II Chemical Distributed to the Transferee. MUST be returned within 30 days of date of actual
import (9d) 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:
DEA form - 486 (Previous version obsolete.)
9/30/2016

DATE:

Copy 41