Lacey Act Declaration Form

Plant and Plant Product Import Declaration (cont.)
SECTION 2 - Compliance with Lacey Act Requirements ( 16 U.S.C. 3372 (f) )
. DESCRIPTION OF MERCHANDISE: . HTSUS NUMBER: (no dashes/symbols)
9 4 0 0 0 0 0
BED
9403.50.0000
CASE GOODS 9403.60.9000 . ENTERED VALUE: (in U.S. Dollars)
For each article or components of an article, provide the following:
212 - - - - - - -
- - - - - - -
I certify under penalty of perjury that, to the best of my knowledge and belief, the information furnished in true and correct:
6-Dec
Type or Print Name
Knowing 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).
PCS
PCS
14. PLANT SCIENTIFIC NAME:
(Genus and Species)
15. COUNTRY OF
HARVEST:
INDONESIASWIETENIA MACROPHYLLA
SWIETENIA MACROPHYLLA INDONESIA
10
11
12
3 5 0
16. QUANTITY OF PLANT
MATERIAL
Santy Herdiana
17. UNITS OF
MEASURE:
Date
Signature
Bed made of Mahogany
Case Goods of Mahogany
18. % RECYCLED
MATERIAL:
13. ARTICLE/COMPONENTS
OF ARTICLE