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

OMB APPROVED
0579-0349
EXP.: XX/XXXX

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
SUPPLENTAL FORM

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

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. HTS NUMBER
(no dashes/symbols)

12. ENTERED
VALUE

13. ARTICLE/COMPONENT OF
ARTICLE

14. PLANT SCIENTIFIC NAME
Genus
Species

I certify under perjury that, to the best of my knowledge and belief, the information furnished is true and correct.
PREPARER’S NAME (printed)
PREPARER’S SIGNATURE
EMAIL ADDRESS

PPQ FORM 505B
JUN 2016

15. COUNTRY
OF HARVEST

16. QUANTITY
OF PLANT
MATERIAL

17. UNIT

TELEPHONE NUMBER

DATE (MM/DD/YYYY)

(NOTE: Knowingly making any false statement in this Declaration for importation may subject the declarant to criminal penalties in accordance with 16 U.S.C. 3373(d)).
(Previous editions are obsolete.)

18. PERCENT
RECYCLED