486 (page 2) Import/Export Declaration for List I and List II Chemica

U.S. Department of Justice / Drug Enforcement Administration

IMPORT / EXPORT DECLARATION for List I and List II Chemicals
(read instructions and Privacy Act before completing)

OMB Approval No. 1117-0023
Expiration Date: 11/30/2019

For Importers Only: Complete "a" and "b" for each Transferee upon the initial declaration. Complete "c" after each distribution to each Transferee until
the listed chemical is completely distributed. Use a separate sheet if more than 3 Transferees.
6a. Transferee (U.S. company name, address, and telephone number)

6b. Name and net weight of listed chemical in KG or parts thereof to be
Imported for this transferee.

DEA Registration No.:
6c. Return Information: Net weight and actual date the listed chemical is distributed to Transferee. If the listed chemical is not completely distributed,
submit Return Information within 30 days of each subsequent distribution.

7a. Transferee (U.S. company name, address, and telephone number)

7b. Name and net weight of listed chemical in KG or parts thereof to be
Imported for this transferee.

DEA Registration No.:
7c. Return Information: Net weight and actual date the listed chemical is distributed to Transferee. If the listed chemical is not completely distributed,
submit Return Information within 30 days of each subsequent distribution.

8a. Transferee (U.S. company name, address, and telephone number)

8b. Name and net weight of listed chemical in KG or parts thereof to be
Imported for this transferee.

DEA Registration No.:
8c. Return Information: Net weight and actual date the listed chemical is distributed to Transferee. If the listed chemical is not completely distributed,
submit Return Information within 30 days of each subsequent distribution.

Signature of Authorized Individual of Importer/Exporter, Broker, or
Forwarding Agent

Name of Firm and contact information of person submitting Return
Information

Print Name:
DEA Form-486

DEA Transaction No.:

Date:

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