PPQ 505B Plant and Plant Product Declaration Supplemental Form

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0579-0349
EXP.: 04/2022

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

PLANT AND PLANT PRODUCT DECLARATION
SUPPLEMENTAL FORM

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 penalty of 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
APR 2020

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