Form PPQ Form 523 PPQ Form 523 Emergency Action Notification

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 numbers for this information collection are 0579-0088, 0579-0207, 0579-0285, and others. The time required to complete this
information collection is estimated to average between .033 and 1 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

OMB APPROVED

0579-0088, 0207, 0285,
et al
EXP: XX/XXXX

SERIAL NUMBER
1. PPQ LOCATION

2. DATE ISSUED

EMERGENCY ACTION NOTIFICATION
3. NAME AND QUANTITY OF ARTICLE(S)

4. LOCATION OF ARTICLES

5. DESTINATION OF ARTICLES

6. SHIPPER

7. NAME OF CARRIER
8. SHIPMENT ID NUMBER(S)

9. OWNER/CONSIGNEE OF ARTICLES
9a. NAME

10. PORT OF LADING

11. DATE OF ARRIVAL

9b. ADDRESS

12. ID OF PEST(S), NOXIOUS WEEDS, OR ARTICLE(S)

12a. PEST ID NUMBER

12b. DATE INTERCEPTED

13. COUNTRY OF ORIGIN

14. GROWER NUMBER

9c. PHONE NUMBER

9d. FAX NUMBER

15. FOREIGN CERTIFICATE NUMBER

9e. SOCIAL SECURITY NUMBER

9f. TAX IDENTIFICATION NUMBER (TIN)

15a. PLACE ISSUED

15b. DATE

Under Sections 411, 412, and 414 of the Plant Protection Act (7 U.S.C. 7711, 7712, and 7714) and Sections 10404 through 10407 of the Animal Health Protection
Act (7 U.S.C. 8303 through 8306), you are hereby notified, as owner or agent of the owner of said carrier, premises, and/or articles, to apply remedial measures for
the pest(s), noxious weeds, and/or article(s) specified in Item 12, in a manner satisfactory to and under the supervision of an Agriculture Officer. Remedial
measures shall be in accordance with the action specified in Item 16 and shall be completed within the time specified in Item 17.
AFTER RECEIPT OF THIS NOTIFICATION, ARTICLES AND/OR CARRIERS HEREIN DESIGNATED MUST NOT BE MOVED EXCEPT AS DIRECTED BY AN
AGRICULTURE OFFICER. THE LOCAL OFFICER MAY BE CONTACTED AT:
16. ACTION REQUIRED
TREATMENT
RE-EXPORTATION
DESTRUCTION
OTHER

Should the owner or owner's agent fail to comply with this order within the time specified below, USDA is authorized to recover from the owner or
agent cost of any care, handling, application of remedial measures, disposal, or other action incurred in connection with the remedial action,
destruction, or removal.
17. AFTER RECEIPT OF THIS NOTIFICATION, COMPLETE SPECIFIED ACTION
WITHIN (Specify Number of Hours or Number of Days):

18. SIGNATURE OF OFFICER:

19. ACKNOWLEDGMENT OF RECEIPT OF EMERGENCY ACTION NOTIFICATION
I hereby acknowledge receipt of the foregoing notification.
SIGNATURE AND TITLE

DATE AND TIME:
20. REVOCATION OF NOTIFICATION

ACTION TAKEN

SIGNATURE OF OFFICER
PPQ FORM 523
JUL 2014

DATE:
(Previous editions are obsolete.)

PRIVACY ACT STATEMENT
Principal Purposes for Which the Information is Solicited - The principal purpose for which the information
is solicited is for use in delinquent debt collection. The routine uses which may be made of the information
are: (1) Referral to other Federal, State, local or foreign investigative, prosecuting, or enforcement
agencies; (2) Disclosure to the U.S. Department of Justice for use in litigation; (3) Disclosure to a court or
adjudicative body in a proceeding when the use of such records is therefore deemed by the Agency to be
for a purpose that is compatible with the purpose for which the Agency collected the records; (4)
Disclosure may be made to a congressional office from the record of an individual in response to an
inquiry from the congressional office made at the request of that Individual; (5) Information contained in
this system of records may be disclosed to a debt collection agency when the U.S. Department of
Agriculture (USDA) determines such referral is appropriate for collecting the debtor's account as provided
for in U.S. Government contracts with the collection agencies executed pursuant to 31 U.S.C. 3718; (6)
Where prior collection efforts have failed, the USDA will refer to the U.S. Department of the Treasury
information from this system of records concerning past due legally enforceable debts for offset against
tax refunds that may become due the debtors for the tax year in which referral is made in accordance with
Internal Revenue Service regulations at 26 CFR 301.6402-6T, offset of past-due Legally Enforceable
Debt Against Overpayment, and under the authority contained in 31 U.S.C. 3720A; (7) Information
contained in this system of records may be disclosed to a consumer reporting agency in accordance with
31 U.S.C. 3711 (f); (8) Information contained in this system of records, related to non-tax debts or claims
that are delinquent for 180 days, will be sent to the Department of the Treasury or to other Federal
agencies designated by the Secretary of the Treasury for the purpose of offsetting Federal payments to
collect delinquent debts, owed to the Federal Government. Records will be matched by Taxpayer
Identification Number (TIN) and name. For an Individual, the TIN is the social security number. For a
business, the TIN is the Employee Identification Number. The release of this information is in accordance
with 31 U.S.C. 3716 and 4 CFR part 102. Failure to provide the solicited information will not subject you
to penalties or adverse consequences.

PPQ FORM 523 REVERSE