486A (page 2) Import Declaration for Ephedrine, Pseudoephedrine, and P

U.S. Department of Justice / Drug Enforcement Administration

Import Declaration for Ephedrine, Pseudoephedrine, and Phenylpropanolamine
(read instructions and Privacy Act before completing)

OMB Approval No. 1117-0023
Expiration Date: 11/30/2019

For Importers Only: Complete "a" and "b" for each Transferee upon the initial declaration. Complete "c" after each distribution to each Transferee until
the Ephedrine, Pseudoephedrine, or Phenylpropanolamine is completely distributed. Use a separate sheet if more than 3 Transferees.
6a. Transferee (U.S. company name, address, and telephone number)

6b. Name and net weight of Ephedrine, Pseudoephedrine, or
Phenylpropanolamine in KG or parts thereof to be Imported for this
transferee.

DEA Registration No.:
6c. Return Information: Net weight and actual date the Ephedrine, Pseudoephedrine, or Phenylpropanolamine is distributed to Transferee. If the
Ephedrine, Pseudoephedrine, or Phenylpropanolamine is not completely distributed, submit Return Information within 30 days of each subsequent
distribution.

7a. Transferee (U.S. company name, address, and telephone number)

7b. Name and net weight of Ephedrine, Pseudoephedrine, or
Phenylpropanolamine in KG or parts thereof to be Imported for this
transferee.

DEA Registration No.:
7c. Return Information: Net weight and actual date the Ephedrine, Pseudoephedrine, or Phenylpropanolamine is distributed to Transferee. If the
Ephedrine, Pseudoephedrine, or Phenylpropanolamine is not completely distributed, submit Return Information within 30 days of each subsequent
distribution.

8a. Transferee (U.S. company name, address, and telephone number)

8b. Name and net weight of Ephedrine, Pseudoephedrine, or
Phenylpropanolamine in KG or parts thereof to be Imported for this
transferee.

DEA Registration No.:
8c. Return Information: Net weight and actual date the Ephedrine, Pseudoephedrine, or Phenylpropanolamine is distributed to Transferee. If the
Ephedrine, Pseudoephedrine, or Phenylpropanolamine is not completely distributed, submit Return Information within 30 days of each subsequent
distribution.

Signature of Authorized Individual of Importer/Exporter, Broker, or
Forwarding Agent

Name of Firm and contact information of person submitting Return
Information

Print Name:
DEA Form-486A

DEA Transaction No.:

Date:

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