EFTA00523293.pdf

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 wasting data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Exp. Date: SECTION 1 - Shipment Information 6. IMPORTER NAME: Plant and Plant Product Karyna Shuliak I. ESTIMATED DATE OF ARRNAL:(w.voonvm Mar 21,2019 Declaration Form 7. IMPORTER ADDRESS: Section 3: Lacey Act Amendment (16 U.S.C. 3372) 2. ENTRY NUMBER: 358 El Brillo Way W16-5042105-2 APHIS Palm Beach, FL 33480 3. CONTAINER NUMBER: O See Attachment 8. CONSIGNEE NAME: XF975370809FR U.S. DEPARTMENT OF AGRICULTURE Karyna Shuliak ANIMAL AND PLANT HEALTH INSPECTION SERVICE 4. BILL OF LADING: 9. CONSIGNEE ADDRESS: 001-59191241 83017268206 10. DESCRIPTION OF MERCHANDISE: 358 El Brillo Way S. MID: WOODEN TRAYS Palm Beach, FL 33480 The Conran Shop SECTION 2 - Compliance with Lacey Act Requirements (16 U.S.C. 3372(f)) For each ankle or component of an article, provide the following 11. HTSUS NUMBER: 12. ENTERED 13. ARTICLE/ COMPONENT OF ARTICLE 14. PLANT SCIENTIFIC NAME: 15. COUNTRY 16. QUANTITY OF 17. UNIT: 18. PERCENT (no dashes/symbols) VALUE: Gem* Species OF HARVEST: PLANT MATERIAL: RECYCLED: 4 4 1 9 1 9 9 0 0 0 82.36 3 Decorative trays in Birch Plywood Betula Pendula Sweden 0.482 kg 0 4 4 1 9 1 9 9 0 0 0 54.9 2 Decorative trays in Birch Plywood Betula Pendula Sweden 0.227 kg 0 4 4 1 9 1 9 9 0 0 0 54.9 2 Decorative trays in Birch Plywood Betula Pendula Sweden 0321 kg 0 4 4 1 9 1 9 9 0 0 0 59.64 Decorative trays In MDF MOF MDF Belgium 0.498 kg 0 4 4 1 9 1 9 9 0 0 0 74.78 Decorative trays in MDF MOF MDF Belgium 0.598 kg 0 ify penalty of penury that. t I nw knowledge and brief the information furnished is true and correct, Version 08.15.2011.0856 PPQ FORM 505 +33 142841001 7C-Q/tdpioe CCILa el 12/e ie.t. a v4/64 ratet.'0 , 03/49 //5 7 AUGUST 2011 Peones Phone Numbs end Ma Con *row.° Type or Prig Nano Due Page 1 n Troy sacs IM aetlwat ID ennui pertains in axon:lama vnin 16 . 30). EFTA00523293 Version08.15-2011-0856 1. Estimated Date of Arrival: Enter the date (MM/DD/YYYY) that the product is expected to enter the United States of America. 2. Entry Number: Enter the U. S. Customs entry number assigned to this shipment. (Format: xxx-xxxxxxx-x) 3. Container Number: Enter the number of the shipping container in which the product is being shipped - available from your shipping company. If you have more than container number in your shipment, check the "see attachment" box, and list all of the containers on a separate sheet. Attach the container list to the PPQ 505. If there is no container number, please leave this section blank. 4. Bill of Lading: Enter the Bill of Lading (BOL) number assigned to this shipment - available from the shipping company. If there is no Bill of Lading number, please leave this section blank. 5. MID: Manufacturer Identification Code - available from the manufacturer or customs broker (19 CFR Appendix to Part 102). 6. Importer Name: Enter the name of the import company or individual for the product. 7. Importer Address: Enter the address of the import company or individual in #6. 8. Consignee Name: Name of the individual or company who ordered and will ultimately receive the shipment. 9. Consignee Address: Enter the address of the individual or company in #8. 10. Description of the Merchandise: Enter the name of the plant or plant product, and its use (example: wooden spoons for kitchenware). If the use is unknown, enter only the name of the product(example: lumber). If the product is protected under CITES also input CITES permit number here. If product was manufactured prior to the Lacey Act Amendment also input "Manufactured Prior to May 22, 2008". 11. HTSUS Number: Enter the Harmonized Tariff Code for the merchandise described in #10 - available at htlp://www.usitc.govitata/hts/. 12. Entered Value (in U.S. Dollars): Write the entered value of the imported merchandise described in #10 in U.S. Dollars. 13. Article/Component of Article: Enter a brief description of each article, or component of an article, that is manufactured from plants or plant parts. (Example: A decorative item including a wood frame and 100 % recycled paperboard - enter the frame as a line item, and record the percent recycled material in the paperboard in section #18.) 14. Plant Scientific Name: For each article/component in #13 enter the scientific name (example: See next page). If the species of plant used to produce the product varies, and the species used to produce the product is unknown, enter each species that may have been used to produce the product. If product was manufactured prior to the Amendment and you cannot determine species, enter "Special" for Genus and "PreAmendment" for Species. The Scientific Name is NOT the trade/common name of the plant. Page 1 EFTA00523294 Version 08.15.20110856 15. Country of Harvest: Enter the country where the plant was harvested (example: See below). If the country of harvest varies, and is unknown, enter all countries from which the plant material in the product may have been harvested. This is NOT the country of manufacture/origin. 16. Quantity of Material: How much plant material is in the shipment (example: See below). 17. Unit: This is the Unit of Measure of the Plant Material. Use the drop down box on the form to enter the units for #17. (example: See below). kg - kilograms m - meter m2 - square meters m3 - cubic meters 18. % Recycled Material: If the product is paper or paperboard, enter the percentage of recycled material it contains (0 - 100%). If the percentage of recycled material varies, enter the average percentage of recycled material used in the product (example: If the percentage of recycled material used is between 25% and 45%, enter 35%). 11. HTSUS 12. Entered 15.Country of 16. Quantity of 18. Percent 13. Article/Component of Article 14. Plant Scientific Name 17. Unit Number Value Harvest Plant Material Recycled Genus Species 9401692010 1354 Bentwood Seats Made of Oak Quercus lineata Indonesia 500 kg 0 4407950000 8442 European ash lumber (2" x 41 Fraxinus excelsior Switzerland 52 M3 0 Submission of Paper Declaration: Importers should have a copy of the form available for Customs and Border Protection (CBP) to review at the port of entry. After CBP clears the shipment, the importer must mail the original form to the USDA at the following address. The Lacey Act c/o U.S. Department of Agriculture Box 10 4700 River Road Riverdale, MD 20737 Note: You may use Form PPQ 5058 should more space be required. Make as many copies as necessary. Failure to include any and all of the required information will result in the rejection of your declaration. SPECIAL NOTE: IF YOU HAVE FILED A LACEY ACT DECLARATION ELECTRONICALLY THROUGH THE CUSTOMS SYSTEM, THERE IS NO NEED TO FILE A PAPER DECLARATION. Page 2 EFTA00523295