Lacey Act Declaration Form

ManualsBrandsModus Furniture ManualsFurnitureKali Solid Mahogany Live Edge Dining Table

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

OMB APPROVED

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,

0579-0349

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

Exp. Date:

SECTION 1 - Shipment Information

1.ESTIMATED DATE OF ARRIVAL:(MM/DD/YYYY) 6.IMPORTER NAME:

January 20, 2020 Modus Furniture International

2.ENTRY NUMBER: 7.IMPORTER ADDRESS:

5410 Mc Connell Avenue

Los Angeles, CA 90066 U.S.A

3.CONTAINER NUMBER:

DRYU9604093

8.CONSIGNEE NAME:

4.BILL OF LADING:

: City Furniture - fl

: SUB19005369

10.DESCRIPTION OF MERCHANDISE:

9.CONSIGNEE ADDRESS:

5.MID:

16,861.00 6701 N. Hiatus Road

Tamarac, FL 33321 - US

SECTION 2-Compliance with Lacey Act Requirements(16 U.S.C.3372(f))

For each article or component of an article, provide the following:

12.ENTERED VALUE: 16.QUANTITY OF 17.UNIT

(in U.S.Dollars) Genus Species PLANT MATERIAL

9403.50.9045

ROLL SLAT 12 PC QN POPULUS DELTOIDES CHINA 0.2917

m3 0%

9403.50.9045

ROLL SLAT 14 PC CK POPULUS DELTOIDES CHINA 0.0681

m3 0%

9403.50.9045

ROLL SLAT 12 PC EK POPULUS DELTOIDES CHINA 0.3696

m3 0%

9403.50.9080

OCEAN NS NATURAL SENGON albizia lebbeck Indonesia 0.3587

m3 0%

9403.50.9080

OCEAN NS NATURAL SENGON POPULUS DELTOIDES CHINA 0.0237

m3 0%

9403.50.9080

OCEAN NS NATURAL SENGON SHOREA Laevis Ridl INDONESIA 0.0237

m3 0%

9403.50.9080

OCEAN NS NATURAL SENGON SPECIAL MDF MALAYSIA 0.0320

m3 0%

9403.50.9080

OCEAN NS NATURAL SENGON Swietenia Macrophylla Indonesia 0.0307

m3 0%

9403.50.9080

OCEAN DRESSER NATURAL SENGON

albizia lebbeck Indonesia 0.5570

m3 0%

9403.50.9080

OCEAN DRESSER NATURAL SENGON

POPULUS DELTOIDES CHINA 0.0193

m3 0%

9403.50.9080

OCEAN DRESSER NATURAL SENGON

SHOREA Laevis Ridl INDONESIA 0.0193

m3 0%

9403.50.9080

OCEAN DRESSER NATURAL SENGON

SPECIAL MDF MALAYSIA 0.1699

m3 0%

9403.50.9080

OCEAN DRESSER NATURAL SENGON

Swietenia Macrophylla Indonesia 0.1007

m3 0%

9403.50.9080

OCEAN DRESSER MIRROR NATURAL SENGON albizia lebbeck Indonesia 0.0490

m3 0%

9403.50.9080

OCEAN DRESSER MIRROR NATURAL SENGON SPECIAL MDF MALAYSIA 0.1748

m3 0%

9403.50.9080

OCEAN CHEST NATURAL SENGON albizia lebbeck Indonesia 0.1333

m3 0%

9403.50.9080

OCEAN CHEST NATURAL SENGON POPULUS DELTOIDES CHINA 0.0396

m3 0%

9403.50.9080

OCEAN CHEST NATURAL SENGON SHOREA Laevis Ridl INDONESIA 0.0396

m3 0%

9403.50.9080

OCEAN CHEST NATURAL SENGON SPECIAL MDF MALAYSIA 0.0418

m3 0%

9403.50.9080

OCEAN CHEST NATURAL SENGON Swietenia Macrophylla Indonesia 0.0200

m3 0%

9403.50.9045

OCEAN QN SR+CS+LS NATURAL SENGON albizia lebbeck Indonesia 0.0173

m3 0%

11.HTSUS NUMBER:

13.ARTICLE/COMPONENT OF

14.PLANT SCIENTIFIC NAME:

Plant and Plant Product

Declaration Form

Section 3: Lacey Act Amendment (16 U.S.C. 3372)

U.S.DEPARTMENT OF AGRICULTURE

15.COUNTRY OF

18. PERCENT RECYCLED

(no dashes/symbols)

ARTICLE

HARVEST:

MATERIAL:

Summary of content (4 pages)

PAGE 1
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 OMB APPROVED 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.
PAGE 2
9403.50.9045 OCEAN QN SR+CS+LS NATURAL SENGON POPULUS DELTOIDES CHINA 0.1544 m3 0% 9403.50.9045 OCEAN QN SR+CS+LS NATURAL SENGON Swietenia Macrophylla Indonesia 0.0904 m3 0% 9403.50.9045 OCEAN QN HB+FB NATURAL SENGON albizia lebbeck Indonesia 0.3736 m3 0% 9403.50.9045 OCEAN QN HB+FB NATURAL SENGON SPECIAL MDF MALAYSIA 0.0102 m3 0% 0.1269 m3 0% 0% 9403.50.9045 OCEAN QN HB+FB NATURAL SENGON Swietenia Macrophylla Indonesia 9403.50.
PAGE 3
9403.50.9045 TAHOE EK SR+CS+LEG UMBER_GREY Swietenia Macrophylla Indonesia 0.0269 m3 0% 9403.50.9045 TAHOE CK HB UMBER_GREY albizia lebbeck Indonesia 0.0084 m3 0% 9403.50.9045 TAHOE CK HB UMBER_GREY SPECIAL MDF MALAYSIA 0.0878 m3 0% 9403.50.9045 TAHOE CK FB UMBER_GREY albizia lebbeck Indonesia 0.0366 m3 0% 0.0434 m3 0% 0% 9403.50.9045 TAHOE CK SR+CS+LEG UMBER_GREY albizia lebbeck Indonesia 9403.50.9045 TAHOE CK SR+CS+LEG UMBER_GREY POPULUS DELTOIDES CHINA 0.
PAGE 4
14. Plant Scientific Name: For each article/component in #13 enter the scientific name (example: See next page). If the species of plant used to produce the product varies, and the species used to produce the product is unknown, enter each species that may have been used to produce the product. If product was manufactured prior to the Amendment and you cannot determine species, enter "Special" for Genus and PreAmendment for Species. The Scientific Name is NOT the trade/common name of the plant. 15.