Schedule 3

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)

U.S. DEPARTMENT OF COMMERCE
Bureau of Industry and Security

DATE RECEIVED
(Leave Blank)

CWC SCHEDULE 3
DECLARATION OR REPORT
CERTIFICATION FORM
Provide the information requested below in Questions C.1 through C.8.

C.1
C.2
C.3

Name of Declaration or Report Point of Contact (D/R-POC):
Company Name:
Mailing Address:
State:

City:
D/R-POC's Telephone Number:

C.4

Zip Code:
ext.

D/R-POC's Fax Number:
D/R-POC's E-mail Address:

C.5

Date Submitted (YYYY-MM-DD):

C.6

CERTIFICATION

I hereby certify that I have reviewed the attached documents and that, to the best of my knowledge and belief, the
submitted information is true and complete.
Name and title of responsible official (type or print):
Signature:

Date Signed (YYYY-MM-DD):
TYPE OF DECLARATION OR REPORT

(check one box, except check two boxes for an amendment)

ANNUAL DECLARATION ON PAST ACTIVITIES (YYYY): ___________
ANNUAL REPORT ON EXPORTS AND IMPORTS (YYYY): ___________
COMBINED ANNUAL DECLARATION AND REPORT (YYYY): ___________

C.7
ANNUAL DECLARATION ON ANTICIPATED ACTIVITIES (YYYY): ___________
DECLARATION ON ADDITIONALLY PLANNED ACTIVITIES (YYYY): ___________

AMENDMENT

Forms Submitted

C.8

Check all forms that are included:
FORM 3-1

FORM 3-2

FORM 3-3

FORM A

FORM B

CERTIFICATION FORM Schedule 3 Declaration or Report
Declaration and reporting requirements are set forth in Part 714
of the CWC Regulations (15 CFR 714).
A separate Certification Form is required for:
(a) each Schedule 3 plant site that has declaration
requirements;
(b) each Schedule 3 plant site with reporting requirements; and
(c) each trading company with reporting requirements.

NOTE: If you submit a combined declaration and report, you
must submit only one Certification form.
If you submit a combined declaration and report, you must
submit only one Certification form.
This form serves several purposes, including:
(a) identifying a Declaration Point of Contact;
(b) certifying the accuracy of the submitted declaration or
report;
(c) identifying the type of declaration or report
submitted; and
(d) listing the declaration or report forms submitted.
Questions C.1 through C.5 Name of Declaration or Report
Point of Contact (D/R-POC) and Other Requested Information:
Designate a D/R-POC. The D/R-POC should be a person
whom the Department of Commerce may contact for: (1) the
purposes of clarification of information provided in the
declaration or report; and (2) for general information. The
D/R-POC need not be the person who prepares the declaration
or report forms or signs the Certification Form.
Question C.6 Certification: The Certification statement must
be signed by the owner, the operator, or a senior management
official who certifies the accuracy and completeness of the
information submitted. The Certification signature block must
contain an original signature.
Question C.7 Type of Declaration or Report: Check the
appropriate box for the type of declaration or report being
submitted (e.g., past activities, anticipated or additionally
planned activities, exports and imports, combined declaration
and report, and amendments) and indicate the year for which
the information applies.

The ANNUAL DECLARATION ON PAST ACTIVITIES
provides information on the production of a Schedule 3
chemical by a declared Schedule 3 plant site for the previous
year. A plant site must submit an ANNUAL DECLARATION
ON PAST ACTIVITIES if one or more plants on the plant site
produced a Schedule 3 chemical above 30 metric tons during
the previous calendar year.
The ANNUAL REPORT ON EXPORTS AND IMPORTS,
submitted by plant sites or trading companies, provides
information on exports and imports of a Schedule 3 chemicals
above 30 metric tons.

The COMBINED ANNUAL DECLARATION AND REPORT
provides information on a declared Schedule 3 plant site
required to submit both an Annual Declaration on Past
Activities and an Annual Report on Exports and Imports. The
COMBINED ANNUAL DECLARATION AND REPORT
provides information on the production of a Schedule 3
chemical above 30 metric tons as well as information on the
export from or import to the plant site of the same or different
Schedule 3 chemical above 30 metric tons. Note that exports
from and imports to a plant site are determined for the entire
plant site, including all units of the plant site.
The ANNUAL DECLARATION ON ANTICIPATED ACTIVITIES provides information on the production of a Schedule 3
chemical by a plant site that has at least one plant that
anticipates producing the Schedule 3 chemical above 30 metric
tons in the next calendar year.
The DECLARATION ON ADDITIONALLY PLANNED
ACTIVITIES provides information on additional activities
planned after submission of the ANNUAL DECLARATION
ON ANTICIPATED ACTIVITIES. NOTE: This declaration is
due 15 days before the additionally planned activities can
begin.
Note that declarations on the production of Schedule 3
chemicals by declared plant sites will be transmitted to the
OPCW and will also be used, where applicable, to compile the
U.S. national aggregate declaration. Reports on Exports and
Imports of Schedule 3 chemicals are not transmitted to the
OPCW, but are used to compile the U.S. national aggregate
declaration.
Question C.8 Forms Submitted: Check the appropriate box for
each form that is included in the submission.

FORM APPROVED: OMB NO. 0694-009 (JAN-2004)
PLANT SITE OR TRADING COMPANY NAME:

CWC SCHEDULE 3
DECLARATION OR REPORT

U.S. PLANT SITE OR TRADING COMPANY CODE
(once assigned):

FORM 3-1 SCHEDULE 3 PLANT SITE OR TRADING COMPANY IDENTIFICATION
Submit this form for each declared Schedule 3 plant site, undeclared Schedule 3 plant site, or
trading company. You must submit this form for each type of declaration or report (past activities,
anticipated or additionally planned activities, exports and imports, combined, and amendments).

3-1.1
3-1.2
3-1.3

Owner:
Telephone Number:

Fax Number:

Operator:
Telephone Number:

Fax Number:

Street Address:
City:

State:

Zip Code:

Provide the geographic coordinates of the center of the plant site (see Supplement No. 1).

3-1.4

a. Latitude (Deg/Min/Sec/N):
b. Longitude (Deg/Min/Sec/W):

Check this box if you have attached to Form A any additional information on the plant site.

3-1.5

The number of declared Scheduled 2 plants at this Schedule 3 plant site: _________

Designation of Inspection Point of Contact (I-POC) for inspection notifications involving this plant site.
NOTE: The Department of Commerce must be able to reach the I-POCs at all hours through the
telephone numbers shown below.
Name of I-POC:

3-1.6.1

I-POC's Primary Telephone Number:

ext.

I-POC's Alternate Telephone Number:

ext.

I-POC's Fax Number:
I-POC's E-mail Address:
Name of Alternate I-POC (optional):

3-1.6.2

I-POC's Primary Telephone Number:

ext.

I-POC's Alternate Telephone Number:

ext.

I-POC's Fax Number:
I-POC's E-mail Address:

FORM 3-1 Schedule 3 Plant Site or Trading Company Identification
Declaration and reporting requirements are set forth in Part 714
of the CWC Regulations (15 CFR 714).
Submit this form for each declared Schedule 3 plant site,
Schedule 3 plant site or trading company. Declared Schedule
3 plant sites must submit this form for each type of declaration
(past activities, anticipated or additionally planned activities,
and amended) and complete questions 3-1.1 through 3-1.5. In
addition, declared plant sites subject to routine inspection
must complete question 3-1.6. Schedule 3 plant sites and
trading companies must report exports and imports above 30
metric tons by completing only questions 3-1.1 through 3-1.3
for their past activities reporting requirements.
All submitters should assign a unique name to the declared or
undeclared plant site or trading company, and record the name
in the appropriate box in the upper right-hand corner of Form
3-1. The Department of Commerce will provide each
submitter with a unique code. This code, hereafter referred
to as a “U.S. Plant Site or Trading Company Code,” will be the
primary means of identifying a plant site or trading company
after the first declaration or report is submitted and the
Department of Commerce assigns a code. The submitter
should use this code on all future declarations or reports.
Questions 3-1.1 through 3-1.4: Provide the name and
telephone and fax numbers of the owner and the operator or

the occupant or the agent in charge of the plant site or trading
company. Provide the address of the plant site or the trading
company. DO NOT PROVIDE A POST OFFICE BOX.
Provide latitude and longitude for the center of the plant site
using the following formats (see Supplement No. 1 for
guidelines on determining geographic coordinates):
Latitude:
Longitude:

000(degree)/00(minute)/00(second)/N
000(degree)/00(minute)/00(second)/W

If the geographic coordinates are not for the center of the plant
site, you must attach to Form A an explanation of the
coordinates (e.g., front gate, Building No. 15). Also, use Form
A to identify any additional information (e.g., maps, drawings)
that you have attached to this declaration to locate this plant
site with reference to the declared coordinates.
Question 3-1.5: Identify the number of declared Schedule 2
plants, if any, within this declared Schedule 3 Plant Site.
Question 3-1.6: Designate an Inspection Point of Contact
(I-POC) and provide telephone and fax numbers, and an e-mail
address so the Department of Commerce may notify you of
inspections of your plant site. You may also designate an
Alternate I-POC. The Department of Commerce must be able
to contact the I-POCs on a 24 hour basis.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
PLANT SITE NAME:

CWC SCHEDULE 3
PLANT DECLARATION

U.S. PLANT SITE CODE (once assigned):

FORM 3-2 DECLARATION ON SCHEDULE 3 PLANT
Submit this form for each declared Schedule 3 plant at the plant site. Use this for all declarations
(past activities, combined, anticipated or additionally planned activities, and amendments).
PLANT NAME:

3-2.1

PLANT CODE (once assigned):

Owner:
Telephone Number:

Fax Number:

Operator:

3-2.2
3-2.3

Telephone Number:

Fax Number:

Structure Name or Building Number:
Provide any additional information that will assist in identifying the location of this plant on the plant site.

3-2.4

Check this box if you have attached any additional information on the plant to Form A.

3-2.5

Provide the Product Group Codes to describe products at this plant (see Supplement No. 2).

FORM 3-2 Declaration of Schedule 3 Plant
Declaration and reporting requirements are set forth in Part 714
of the CWC Regulations (15 CFR 714).
Submit this form for each declared Schedule 3 plant at the
plant site.
Note: Submitters that only have reporting requirements for
exports or imports of a Schedule 3 chemical are not required to
submit this form.
Submitters should assign a unique name to the plant and the
plant site, and record the name in the appropriate boxes in the
upper right-hand corner of Form 3-2. The Department of
Commerce will provide each submitter with a unique code for
each declared plant and plant site. These codes, “U.S. Plant
Code” and “U.S. Plant Site Code,” will be the primary means
of identifying both a plant and a plant site after the first
declaration is submitted and the Department of Commerce
assigns the codes. The submitter should use these codes on all
future declarations for a particular plant or plant site.

Questions 3-2.1 & 3-2.2: Provide the name and telephone and
fax numbers of the owner and the operator or the occupant or
the agent in charge of the plant.
Questions 3-2.1 & 3-2.2: Provide the building name or
structure number, if any, used to designate the plant.
Question 3-2.4: Provide any additional information that will
assist in identifying the location of this plant on the plant site
(e.g., latitude and longitude, street address, landmarks).
Use Form A to identify any additional information (e.g., site
diagrams, maps, drawings) that you are attaching to this
declaration to locate this plant with reference to the declared
coordinates. (Check the box if you are submitting an
attachment to Form A.)
Question 3-2.5: For the main activities at your plant, provide
one or more product group code(s) (Standard International
Trade Classification (SITC) code) that describe the type of
ultimate products manufactured at the plant.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)
PLANT SITE NAME:

CWC SCHEDULE 3 CHEMICAL
DECLARATION OR REPORT

U.S. PLANT SITE OR TRADING COMPANY CODE
(once assigned):

FORM 3-3 DECLARATION OR REPORT ON SCHEDULE 3 CHEMICAL
Submit this form to provide information on each Schedule 3 chemical. Use this form for all types of
declarations and reports (past activities, anticipated or additionally planned activities, exports and
imports, combined, and amendments).
CAS REGISTRY NO.:

CHEMICAL NAME:

COMMON OR TRADE NAME(S)

Complete this question only for the Annual Declaration on Past Activities and Combined Declaration
and Report
a. Quantity produced in metric tons in the previous calendar year:

3-3.1

b. Purposes(s) of production (check box(es)):

30 to 200

above 200 to 1,000

In-line consumption as produced (captive use)

above 1,000 to 10,000

above 10,000 to 100,000

Synthetic intermediate stored and/or used on site
Transfer to other company or industry

above 100,000

Complete this question only for the Annual Declaration on Anticipated Activities and the Declaration
on Additionally Planned Activities
a. Anticipated production quantity in metric tons for the next
calendar year:

3-3.2

b. Anticipated Purposes(s) of production (check box(es)):
In-line consumption as produced (captive use):

30 to 200

above 200 to 1,000

above 1,000 to 10,000

above 10,000 to 100,000

Synthetic intermediate stored and/or used on site
Transfer to other company or industry

above 100,000

If the plant site or trading company exported and/or imported this Schedule 3 chemical, provide the
following information for each recipient or source destination

Export

Import
a. Quantity exported:

3-3.3.1

b. Recipient Destination (see Supplement No. 3):

a. Quantity exported:

3-3.3.2

a. Quantity imported:

3-3.4.1

metric tons

b. Recipient Destination (see Supplement No. 3):

a. Quantity exported:

3-3.3.3

metric tons

metric tons

b. Recipient Destination (see Supplement No. 3):

b. Source Destination (see Supplement No. 3):

a. Quantity imported:

3-3.4.2

metric tons

b. Source Destination (see Supplement No. 3):

a. Quantity imported:

3-3.4.3

metric tons

metric tons

b. Source Destination (see Supplement No. 3):

If additional pages of Form 3-3 for exports and imports of this Schedule 3 chemical are attached, indicate the total number of
pages as follows: page _____ of _____ (e.g., page x of y)

FORM 3-3 Declaration or Report of Schedule 3 Chemical
Declaration and reporting requirements are set forth in Part 714 of the
CWC Regulations (15 CFR 714).
You must submit a separate Form 3-3 for each Schedule 3 chemical and
for all types of declaration and report (past activities, anticipated or
additionally planned activities, exports and imports, combined
declaration and report, and amended). NOTE: If you are submitting
an ANNUAL DECLARATION ON ANTICIPATED OR ADDITIONALLY PLANNED ACTIVITIES, only complete question 33.2.
Declared plant site: If one or more plants on your plant site produced or
is anticipated to produce more than 30 metric tons of a Schedule 3
chemical, your plant site is a declared plant site and you must complete
questions 3-3.1 and 3-3.2. You may also complete questions 3-3.3
and/or 3-3.4 if you exported from or imported to your plant site more
than 30 metric tons of the Schedule 3 chemical. (Note that the export
or import 30 metric ton threshold is a plant site aggregate. The plant
site must report exports and imports from or to all plants at the plant
site exceeding 30 metric tons.)
NOTE: A plant site that is declared because of the production of one
Schedule 3 chemical may also have reporting requirements for another
Schedule 3 chemical that it did not produce, or produced under threshold,
but that it exported or imported in quantities over 30 metric tons. In such
a case, a COMBINED ANNUAL DECLARATION AND
REPORT may be submitted and the plant site must submit a
separate Form 3-3, but complete only questions 3-3.3 and/or 3-3.4 for
that other Schedule 3 chemical.
Undeclared plant site: If no plant on your plant site produced more
than 30 metric tons of any Schedule 3 chemical, but your plant site
exported or imported more than 30 metric tons of a Schedule 3
chemical, you must submit Form 3-3, but only complete questions 33.3 and/or 3-3.4. (Remember that the export or import amount is an
aggregate of exports from or imports to all plants on your plant site.)
Trading company: A trading company that exported or imported over 30
metric tons of a Schedule 3 chemical must submit Form 3-3, but only
complete questions 3-3.3 and /or 3-3.4.
Enter in the upper right-hand corner of this form the name of the plant site
or trading company or the U.S. Plant Site or Trading Company Code (once
assigned) that was listed on the corresponding Form 3-1 (Schedule 3 Plant
Site or Trading Company Identification). Submitters should use this code
on all declarations for a particular plant site.
For each Schedule 3 chemical being declared, provide the CAS Registry
Number, if assigned, Chemical Name, and Common or Trade Name.
Question 3-3.1: For the ANNUAL DECLARATION ON PAST
ACTIVITIES, you must provide the production quantity range for
each Schedule 3 chemical produced at the plant site in the previous
calendar year and specify the purposes of production of the chemical
by checking all of the appropriate categories. To calculate the

production range of a Schedule 3 chemical on your plant site, take the
following steps:
1) Add the production amounts from all plants that individually
produced more than 30 metric tons of the Schedule 3 chemical declared
on this form. (Note: Do not count the production of this chemical from
plants that individually did not exceed the production threshold of 30
metric tons.)
2) Determine the production range in question 3-3.1 and check the
appropriate box to identify the range of production for the Schedule 3
chemical.
Question 3-3.2: For the ANNUAL DECLARATION ON
ANTICIPATED ACTIVITIES, you must provide the production
quantity range for each Schedule 3 chemical you anticipate will be
produced at the plant site in the next calendar year and specify the
anticipated purposes of production of the chemical by checking all of the
appropriate categories. To calculate the production range for your plant
site refer to the steps listed in Question 3-3.1, above.
After THE ANNUAL DECLARATION ON ANTICIPATED
ACTIVITIES has been submitted, you must submit a DECLARATION ON ADDITIONALLY PLANNED ACTIVITIES if you
plan that: a previously undeclared plant on your plant site will
produce a Schedule 3 chemical above 30 metric tons; a declared plant
will produce an additional Schedule 3 chemical above 30 metric tons;
an increase to the production range of a Schedule 3 chemical by
declared plants on your plant site will exceed the applicable
inspection threshold; or an increase in the aggregate production of a
Schedule 3 chemical at a declared plant site to an amount above the
upper limit of the range previously declared.
Questions 3-3.3 and 3-3.4: For the ANNUAL REPORT OF
EXPORTS AND IMPORTS or COMBINED ANNUAL
DECLARATION AND REPORT (previous calendar year),
complete questions 3-3.3 and/or 3-3.4, as appropriate.
To calculate the export and import amounts for your plant site or
trading company and the source and recipient destinations, take the
following steps:
1) Add all exports from your plant site or trading company. Plant
sites must total exports from all plants on the plant site to obtain the
plant site export aggregate. Add all imports to your plant site or trading
company. Plant sites must total all imports to all plants on the plant
site to obtain the plant site import aggregate.
2) Determine the total exports to each recipient destination.
Determine the total imports from each source destination. (Use
Supplement No. 3 identify the Destination Code.)
3) Indicate in questions 3-3.3 and/or 3-3.4, as appropriate, the
number of metric tons of the Schedule 3 chemical exported to each
recipient destination or imported from each source destination.
If there is insufficient space to record all of your export or import trade
transactions, use additional copies of Form 3-3. Indicate the page
number of each additional page and total number of pages of Form 3-3
for this chemical.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)

COMPLETE AS MANY COPIES OF THIS FORM AS NECESSARY.

CWC SCHEDULE 3
FORM A

Use this form to describe any attachment to this declaration or report.
Attachments may include, for example, any additional information on the
precise location of a declared plant site, site map.

FORM A ATTACHMENTS FOR SCHEDULE 3 PLANT SITE
OR TRADING COMPANY
Plant Name

Form Number

Plant Site or Trading Company Name:

Identify each attachment with a unique name or description.

FORM A Attachments for Schedule 3 Plant Site or Trading Company
Declaration and reporting requirements are set forth in Part 714 of the CWC Regulations (15 CFR 714).
Submit this form to list any attachments containing additional information (e.g., site diagrams, maps, drawings, chemical
structural formula).
PLANT SITE OR TRADING COMPANY NAME: Enter the name of the plant site or trading company, and if assigned, enter its
U.S. Plant Site or Trading Company Code.
PLANT NAME: If providing information on a plant, enter in column 1 the name of the plant, and once assigned, enter its U.S. Plant
Code.
FORM NUMBER: In column 2, enter the form number to which this additional information refers.
IDENTIFY ATTACHMENT: In column 3, provide a description of the attachment and assign a unique name to it (e.g., site map).
For structural formulas, provide the CAS Registry Number, if assigned, chemical name and/or common trade name.
Insert all attachments in an envelope and staple the envelope to Form A.

FORM APPROVED: OMB NO. 0694-0091 (JAN-2004)

CWC SCHEDULE 3
FORM B
FORM B OPTIONAL COMMENTS
Comments on form number ____________, question number ______________:

B.1.1

Comments on form number ____________, question number ______________:

B.1.2

Comments on form number ____________, question number ______________:

B.1.3

Comments on form number ____________, question number ______________:

B.1.4

Comments on form number ____________, question number ______________:

B.1.5
Comments on form number ____________, question number ______________:

B.1.6

General comments or suggestions:

B.2.1

FORM B Optional Comments
Declaration and reporting requirements are set forth in Part 714 of the CWC Regulations (15 CFR 714).
Please use this form to record comments or suggestions. Use as many copies of this form as necessary. Submission of this form is
optional, and the information provided will be used only by the Department of Commerce to improve the forms and the CWC
reporting process.