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

U.S. Department of Justice / Drug Enforcement Administration

IMPORT / EXPORT DECLARATION for List I and List II Chemicals

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

(read instructions and Privacy Act before completing)
Type of Declaration:
EXPORT

DEA Transaction No.*:
Date of Issue:
Date of Expiration:

INTERNATIONAL

Reference No.:

IMPORT (Not for U.S. Imports of Ephedrine, Pseudoephedrine, and Phenylpropanolamine)

*This declaration is not deemed filed, and therefore is not valid, until the Drug Enforcement Administration (DEA) has issued a DEA Transaction number
1a. Importer/Exporter/Broker or Trader (company name and address)

1b. If import or export list Customs Broker/Forwarding Agent. If International
list Foreign Consignee. (company name and address)

DEA Registration No.:
1c. I certify the conditions for the waiver of the 15-day advance notice have been met
A 15-day advance notice is required for an initial shipment or for a company that has lost regular importer or regular customer status. See 21
C.F.R. § 1313.12 for further details.
2. Listed Chemicals to be Imported, Exported, or Brokered
2a. Name and description of each listed
chemical as it appears on the label or
container(s)

2b. The name of each listed chemical as 2c. Number and size of container(s),
designated by Title 21 § 1310.02; DEA
net weight of each listed chemical in
Chemical Code Number
KG or parts thereof

2d. Return Information
(see instructions)

3b. Port of Import:
and anticipated Date of Arrival:

3a. Port of Export:
and anticipated Date of Departure:
4. Mode of Transport and name(s) of carrier or vessel:

5. Foreign Consignee/Consignor. If International list Foreign Consignor. (co. name and address)

Foreign Import Permit No.:
Date of Issue:
Date of Expiration:
Provide the foreign permit, license or registration issued by the
Competent National Authority (CNA) of the consignee. See 21
C.F.R. § 1313.22. A CNA usually issues a permit for imports of
substances in Table I of the 1988 Convention.

Signature of Authorized Individual of Importer/Exporter, Broker, or
Forwarding agent
Print Name:

Name of Firm and contact information of person submitting DEA Form-486

Date:

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DEA Form-486

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