Form PPQ 505B PPQ 505B Plant and Plant Product Declaration Supplemental Form

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
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,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Plant and Plant Product
Declaration Supplemental Form

OMB APPROVED
0579-0349
Exp. Date:

U.S. DEPARTMENT OF AGRICULTURE
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:
(no dashes/symbols)

12. ENTERED
VALUE:

13. ARTICLE/ COMPONENT OF ARTICLE

14. PLANT SCIENTIFIC NAME:
Genus

Species

15a. COUNTRY 16. QUANTITY OF 17. UNIT: 18. PERCENT
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 03-01-2011-0856
PPQ FORM 505B
MARCH 2011

Preparer's Phone Number and Area Code

Signature

of

Type or Print Name

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).

Date