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UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE
PLANT AND PLANT PRODUCT DECLARATION
SUPPLEMENTAL FORM
SECTION 3 – Lacey Act Amendment (16 U.S.C. 3372)
ENTRY NUMBER
PAGE
OF
For each article or component of an article, provide the following:
11. HTS NUMBER
(no dashes/symbols)
12. ENTERED
VALUE
13. ARTICLE/COMPONENT OF
ARTICLE
14. PLANT SCIENTIFIC NAME
Genus
Species
I certify under penalty of perjury that, to the best of my knowledge and belief, the information furnished is true and correct.
PREPARER’S NAME (printed)
PREPARER’S SIGNATURE
EMAIL ADDRESS
PPQ FORM 505B
APR 2020
15. COUNTRY
OF HARVEST
16. QUANTITY
OF PLANT
MATERIAL
17. UNIT
TELEPHONE NUMBER
DATE (MM/DD/YYYY)
(NOTE: Knowingly making any false statement in this Declaration for importation may subject the declarant to criminal penalties in accordance with 16 U.S.C. 3373(d)).
(Previous editions are obsolete.)
18. PERCENT
RECYCLED
File Type | application/pdf |
File Modified | 2020-04-24 |
File Created | 2020-04-22 |