Plant And Plant Product Declaration Supplemental Form - Aphis

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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

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).