According to the Paperwork Reduction Act of 1995, no persons are 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 1.5 hours per response, including the time for reviewing instructions, FORM APPROVED
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. OMB No. 0579-0349

Plant and Plant Product U.S. DEPARTMENT OF AGRICULTURE

Declaration Form
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

Section 3: Lacey Act Amendments of 2008 (16 U.S.C. 3372)

Applicability of Declaration:

You are required to complete this form if you are importing any of the following:
Any wild member of the plant kingdom, including roots, seeds, parts, or products thereof, and including
trees from either natural or planted forest stands, except:

1. Common cultivars, except trees, and common food crops (including roots, seeds, parts, or products thereof);
2. * Scientific specimens of plant genetic material (including roots, seeds, germplasm, parts, or products thereof)
that are to be used only for laboratory or field research;
3. * Plants that are to remain planted or to be planted or replanted; or
4. Plants used exclusively as packaging material to support, protect, or carry another item, unless the packaging
material itself is the item being imported.

* You must still complete this form if you are importing plants described under 3. and 4. that are listed:

· In an appendix to the Convention on International Trade in Endangered Species of Wild Fauna and Flora
(27 UST 1087; TIAS 8249);
· As an endangered or threatened species under the Endangered Species Act of 1973 (16 U.S.C. 1531 et seq.); or
· Pursuant to any State law that provides for the conservation of species that are indigenous to the State and are
threatened with extinction.

SECTION 1 - Shipment Information

1. ESTIMATED DATE OF ARRIVAL: (MM/DD/YYYY)
11/20/2024
2. ENTRY NUMBER: 3. CONTAINER NUMBER:
1ZR8E2200409969669
4. BILL OF LADING: 5. MID:

6. IMPORTER NAME: 8. CONSIGNEE NAME:

JACK E PETIT JACK E PETIT
7. IMPORTER ADDRESS: 9. CONSIGNEE ADDRESS:
13385 Damonte View Lane 13385 Damonte View Lane
Reno, NV 89511 Reno, NV 89511
United States United States

I certify under penalty of perjury that the information furnished is true and correct:

Signature Type or Print Name Date

Knowingly 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).
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Plant and Plant Product Import Declaration (cont.)

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

10. DESCRIPTION OF MERCHANDISE: 11. HTSUS NUMBER:
WOODEN COFFEE TABLE 9403.60
12. ENTERED VALUE: (in U.S. Dollars)
201
For each article or component of an article, provide the following:
13. ARTICLE/ COMPONENT OF 14. PLANT SCIENTIFIC NAME: 15. COUNTRY OF 16. QUANTITY OF 17. UNIT OF 18. % RECYCLED
ARTICLE (Genus and Species) HARVEST: PLANT MATERIAL: MEASURE: MATERIAL:

WALNUT WOOD COFFEE TABLE JUGLANS REGIA INDIA 1 pcs. 0

I certify under penalty of perjury that the information furnished is true and correct:

Signature Type or Print Name Date

Knowingly 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).
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Version 12-08-2008-0856

1. Estimated Date of Arrival: Enter the date (MM/DD/YYYY) that the product is expected to
enter the United States of America.

2. Entry Number: Enter the U. S. Customs entry number assigned to this shipment.
(Format: xxx-xxxxxxx-x)

3. Container Number: Enter the number of the shipping container in which the product is being
shipped - available from your shipping company. If there is no container number, please leave
this section blank.

4. Bill of Lading: Enter the Bill of Lading (BOL) number assigned to this shipment - available from
the shipping company. If there is no Bill of Lading number, please leave this section blank.

5. MID: Manufacturer Identification Code - available from the manufacturer or customs broker
(19 CFR Appendix to Part 102).

6. Importer Name: Enter the name of the import company or individual for the product.

7. Importer Address: Enter the address of the import company or individual in #6.

8. Consignee Name: Name of the individual or company who ordered and will ultimately receive
the shipment.

9. Consignee Address: Enter the address of the individual or company in #8.

10. Description of the Merchandise: Enter the name of the plant or plant product, and its use
(example: wooden spoons for kitchenware). If the use is unknown, enter only the name of the product
(example: lumber).

11. HTSUS Number: Enter the Harmonized Tariff Code for the merchandise described in #10
- available at http://www.usitc.gov/tata/hts/.

12. Entered Value (in U.S. Dollars): Write the entered value of the imported merchandise described
in #10 in U.S. Dollars.

13. Article/Component of Article: Enter a brief description of each article, or component of an article,
that is manufactured from plants or plant parts. (Example: A decorative item including a wood
frame and 100 % recycled paperboard - enter the frame as a line item, and record the percent
recycled material in the paperboard in section #13.)

14. Plant Scientific Name: For each article/component in #14 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.

1
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15. Country of Harvest: Enter the country of origin (where the plant was harvested) (example:
See below). If the country of harvest varies, and is unknown, enter all countries from which
the plant material in the product may have been harvested.

16. Quantity of Material: How much product/merchandise is in the shipment (example: See below).

17. Unit of Measure: Use the drop down box on the form to enter the units for #17.
(example: See below).

doz - dozen
kg - kilograms
m - meter
m2 - square meters
m3 - cubic meters
No. - number
pcs - pieces
t - metric tons
bf - board feet

18. % Recycled Material: If the product is paper or paperboard, enter the percentage of recycled
material it contains (0 - 100%). If the percentage of recycled material varies, enter the average
percentage of recycled material used in the product (example: If the percentage of recycled
material used is between 25% and 45%, enter 35%).

13. ARTICLE/COMPONENT OF 14. PLANT SCIENTIFIC 15. COUNTRY OF 16. QUANTITY OF 17. UNIT OF 18. % RECYCLED
ARTICLE: NAME: (Genus and Species) HARVEST: PLANT MATERIAL: MEASURE: MATERIAL

Tables made of Mahogany Swietenia macrophylla Indonesia 500 No. 15

European ash lumber
Fraxinus excelsior Switzerland 352,000 BF 0
(2" x 4')

19. Submission of Paper Declaration: Importers should have the form available for Customs and Border
Protection (CBP) to review at the port of entry. After CBP clears the shipment, the importer must mail the
form to the USDA at the following address:

The Lacey Act

c/o U.S. Department of Agriculture
Box 10
4700 River Road
Riverdale, MD 20737

Note: Sign and Print your name, and write the date on both sections of the form.