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
OMB APPROVED
number. The valid OMB control number for this information collection is 0579-0349. The time required to complete this information collection is estimated to average 0.5 hours per response,
0579-0349
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Exp. Date:
Plant and Plant Product
U.S. DEPARTMENT OF AGRICULTURE
Declaration Supplemental Form
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
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. HTSUS NUMBER:
12. ENTERED
13. ARTICLE/ COMPONENT OF ARTICLE
14. PLANT SCIENTIFIC NAME:
15a. COUNTRY
16. QUANTITY OF
17. UNIT:
18. PERCENT
Genus
Species
(no dashes/symbols)
VALUE:
OF HARVEST:
PLANT MATERIAL:
RECYCLED:
I certify under penalty of perjury that, to the best of my knowledge and belief, the information furnished is true and correct:
Version 08-15-2011-0856
PPQ FORM 505B
AUGUST 2011
Preparer's Phone Number and Area Code
Signature
Type or Print Name
Date
Knowingly making a false statement in this Declaration for Importation may subject the declarant to criminal penalties in accordance with 16 U.S.C. 3373(d).